A Review of the Use of Positive Reinforcement in Drug Courts Katherine Bascom Philadelphia College of Osteopathic Medicine

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2019 A Review of the Use of Positive Reinforcement in Drug Courts Katherine Bascom Philadelphia College of Osteopathic Medicine

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Philadelphia College of Osteopathic Medicine

School of Professional and Applied Psychology

A REVIEW OF THE USE OF POSITIVE REINFORCEMENT IN DRUG COURTS

By Katherine Bascom

Submitted in Partial Fulfillment of the Requirements of the Degree of

Doctor of Psychology

June 2019 DISSERTATION APPROVAL

Th is is to certify th at the thesis presented to us by -----"/'-v-'-/k'-=l'--'1f1"'b"'-__..&"'-"'St;=6'-M____,___ _ ' on the ___,_9_fli ___ day of_----"-l't_._u,,_7_,______, 2o_jj__, in partial fulfillment of the requirements for the degree of Doctor of Psychology, has been examined and is acceptable in both scholarship and literary quality.

COMMITTEE MEMBERS' SIGNATURES

Chairperson

Chair, Department of Clinical Psychology

Dean, School of Professional & Applied Psycholog POSITIVE REINFORCEMENT IN DRUG COURTS iii

Acknowledgements

I would first like to thank my committee members, Dr. David Festinger, Dr. Stephanie

Felgoise, and Dr. Alexander Skolnick for their guidance and support throughout this process.

Specifically, Dr. Festinger who helped me with the development of this study and provided me with timely edits and suggestions. Thank you to Dr. DiTomasso and Angelika for their assistance in creating my online survey.

I also would like to thank my mom and dad, for their encouragement and support throughout this doctoral program and dissertation process. I greatly appreciate your commitment to my education, and I attribute my strong work ethic to you both.

Lastly, I want to thank Greg Orton for inspiring my dissertation and work, and my boyfriend and friends for their love and support over the years. A huge thank-you to Doug

MacDonald for his unconditional love, listening, support, understanding, sense of humor, and willingness to constantly move! Also, a huge thank you to Shanna Drinkwine, my favorite study pal. There are no stronger script writing, comps studying, STEPPS prepping, test taking teams than you and me! Thank you for all the laughs, adventures, cuddles with Cabella, and endless support over the last 5 years! I would not be here without you! And Mason, thank you for the unconditional love and happiness you gave me throughout my internship year.

POSITIVE REINFORCEMENT IN DRUG COURTS iv

Abstract

There is a need to provide effective treatment for drug-abusing offenders, as evidenced by the explicitly supported relationship between drug use and crime (Anglin & Perrochet, 1998; Tonry

& Wilson, 1990; McBride & McCoy, 1993). Drug policy in the United States has viewed drug abuse as a public safety concern or a public health concern (Marlowe, 2002). In 1989, the Miami

Drug Court in Dade County, Florida developed a drug court system that is currently used nationwide. The model embodies a very strong behavioral orientation with clear expectations, as well as graduated sanctions and rewards for successive infractions and accomplishments. The use of positive reinforcement is a major component of contingency management (CM). CM is an evidence-based practice that promotes behavior change through systematic reinforcement of desired behaviors with rewards and punishment, or withholding of reinforcement for undesired behaviors (Higgins & Petry, 1999). This survey-based, mixed methods study assessed (1) the frequency of the use of positive reinforcement, currently or in the past, (2) stakeholders’ beliefs about the use of positive reinforcement in their programs, (3) the forms of positive reinforcement currently being used, and (4) the ways in which they implement positive reinforcement into their programs. Thirty-nine drug court coordinators from pre-trial/pre-sentencing drug courts in the

United States of America participated in the survey. Of the 39 drug court coordinators who participated in this study, 37 reported that they use positive reinforcement/rewards in their drug court. Incentivizing productive behaviors is a key element that is listed under the NADCP’s adult drug court best practice standards. Incentives and rewards are critical elements of drug courts; these must be included in order to meet the acceptable standards of competencies as set forth by their association (NADCP, 2018).

Keywords: drugs, treatment, drug courts, positive reinforcement POSITIVE REINFORCEMENT IN DRUG COURTS v

TABLE OF CONTENTS

ABSTRACT…………………………….……………..……………………………… iv INTRODUCTION…………………….…………….………………………………… 1 STATEMENT OF PROBLEM…….……………………………………………… 1 PURPOSE OF STUDY…….……………………………………………………. 31 RESEARCH QUESTION…………….…………………………………………. 33 METHOD………………….…………..……………….…………………………… 34 DESIGN……………………..…………………….…………………………...... 34 PARTICIPANTS……….………...…………………………………………..…. 34 INCLUSION AND EXCLUSION CRITERIA..…….………………………….. 35 MATERIALS………...…………………………………………………………. 35 PROCEDURE……………………………………..……………………………. 37 RESULTS…………………..……………...………………………………………... 39 ANALYSES………………………………...…………….…………………….. 39 DISCUSSION……………………….………………….………………………….. 70 REFERENCES………………….…………………….…………………………… 85 TABLES…………………….……………………………………………………... 95 FIGURES…………………………………………………………………………. 123

Running head: POSITVE REINFORCEMENT IN DRUG COURTS

Introduction

Statement of the Problem:

There is a tremendous need to provide effective treatment for drug-abusing offenders, as evidenced by the explicitly supported relationship between drug use and crime (Anglin & Perrochet, 1998; Tonry & Wilson, 1990; McBride & McCoy, 1993).

Drug users, specifically heavy users, are extremely likely to commit crimes (National

Institute of Justice, 1999) to support their addiction. Although many offenders have drug abuse problems that are associated with their criminal lifestyles, only a small number of them receive treatment during their involvement with the criminal justice system. Only about 13-14% of drug and alcohol-using jail inmates participated in some form of substance abuse treatment since their admission to jail, and only about 15% of state prisoners reported participation in any treatment since their admission to prison (Mumola,

1999).

Historically, drug policy in the United States has viewed drug abuse as a public safety concern or a public health concern (Marlowe, 2002). Over the years, many different public safety and public health approaches have been implemented. Some approaches combined both public safety and public health goals. However, all of these approaches failed to rehabilitate drug abusing offenders or reduce criminal recidivism

(Marlowe, 2002).

Therefore, in 1989, the Miami Drug Court in Dade County, Florida developed a drug court system that is currently used nationwide and addresses the underlying drug abuse problems of offenders and criminal recidivism. Drug courts identify drug-abusing offenders early on, following arrest, and offer them the voluntary opportunity to POSITIVE REINFORCEMENT IN DRUG COURTS 2 participate in a course of treatment and case management under the close supervision of the judge, instead of adjudication and potential incarceration (Burdon, Roll, Prendergast,

& Rawson, 2001). During the 1990s, drug courts became increasingly popular. Since their development in 1989, over 3,000 drug courts have emerged across the United States

(U. S. Department of Justice, 2016). These drug courts offer a new model as a response to the growing number of offenders with drug abuse problems, who cycle through the criminal justice systems without receiving or completing any treatment (Burdon et al.,

2001).

There are ten key components to the drug court model: 1) Integration of alcohol and other drug treatment services with justice system case processing; 2) a nonadversarial approach, with prosecution and a defense counsel that promotes public safety and protects participants’ due process rights; 3) early identification and prompt placement in the drug court program; 4) access to a continuum of alcohol, drug, and other related treatment and rehabilitation services; 5) abstinence monitoring by frequent alcohol and drug testing; 6) a coordinated strategy that governs drug court responses to participants’ compliance and noncompliance via graduated sanctions and rewards; 7) ongoing judicial interaction with each participant; 8) monitoring and evaluation of the achievement of program goals to gauge effectiveness; 9) interdisciplinary education to promote effective drug court planning, implementation, and operations, and 10) forging partnerships among drug courts, public agencies, and community-based organizations (U.S. Department of

Justice, 1997).

Drug court treatment programs vary according to individual clinical needs, but overall, there are many benefits to participation in a drug court program. Benefits POSITIVE REINFORCEMENT IN DRUG COURTS 3 include: substance abuse treatment, mental health treatment, vocational counseling, educational assistance and housing assistance (Marlowe, 2010). Some programs also prevent an individual from incurring a criminal record, if they successfully complete the program. Additionally, drug courts significantly reduce drug use and crime while saving money (Marlowe, 2010).

Another distinct feature of drug courts is that they adopt the Diversion Model to address individual help-seeking beliefs, health services policies, and community provider and criminal justice biases against substance abusing offenders, which have often interfered with this population’s access to services. Under this model, non-violent drug offenders, who are facing adjudication and potential incarceration, are diverted from criminal justice settings to residential community treatment (Broner, Nguyen, Swern, &

Goldfinger, 2003). This allows for significantly more community supervision and substance abuse treatment for offenders than standard pre-trial supervision or probation programs (Festinger, Marlowe, Lee, Kirby, Bovasso, & McLellan, 2002).

Notably, drug courts adhere to a model of “therapeutic jurisprudence”, which represents an approach different from other courts and services in the United States legal and justice systems. Specifically, therapeutic jurisprudence is an attempt to monitor the impact on the emotional life and psychological well-being of individuals affected by decisions of the justice system (Winick, 1997). Overall, drug courts embody therapeutic jurisprudence and the diversion approach, which results in a reduction in drug abuse and criminal recidivism and addresses both public safety and public health.

A particularly unique quality of the drug court model is that it generally embodies a very strong behavioral orientation and provides clear expectations and graduated POSITIVE REINFORCEMENT IN DRUG COURTS 4 sanctions and rewards for successive infractions and accomplishments. Drug courts heavily utilize the punishment aspect of behavioral interventions, via graduated sanctions; however, they do not often use positive reinforcement for appropriate behaviors. Positive reinforcement is more effective in maintaining long term behavior change than is negative reinforcement (Martin & Pear, 2014). Unfortunately, sanctions are more readily available than rewards within drug courts. This is problematic because positive reinforcement is more effective than punishment in changing behaviors, especially for criminal offenders (Martin & Pear, 2014).

The use of positive reinforcement and rewards is a major component of a specific behavioral intervention known as contingency management (CM). CM is an evidence based practice that promotes behavior change through systematic reinforcement of desired behaviors with rewards and punishment or withholding of reinforcement for undesired behaviors (Higgins & Petry, 1999). CM effectively alters a variety of problem behaviors, including multiple types of drug abuse (Kirby, Marlowe, Festinger, Lamb, &

Platt, 1998; Peirce, et al., 2006; Budney, Higgins, Radonovich, & Novy, 2000; Petry,

Martin, Cooney, & Kranzler, 2000; Bickel, Amass, Higgins, Badger, & Esch, 1997;

Silverman, Higgins, Brooner, & Montoya, 1996).

The key to using CM to change behavior is the systematic use of positive reinforcement that is contingent upon the performance of specific behaviors (Burdon et al., 2001). In general, contingency management procedures focus on reinforcement for appropriate behaviors rather than punishment for inappropriate behaviors. CM is one of the most efficacious treatments for substance use disorders (Chambless & Ollendick,

2001), and it is more successful in treating substance use disorders than standard case POSITIVE REINFORCEMENT IN DRUG COURTS 5 management (Higgins & Petry, 1999). Therefore, the drug court model should incorporate positive reinforcement techniques to further improve its effectiveness.

However, despite its vastly supported effectiveness and relative simplicity, many substance abuse programs, including drug courts, have not adopted CM techniques (Petry

& Simcic, 2002). Therefore, it is clear that the majority of drug courts are not benefitting from the use of CM techniques, which has a specific focus on positive reinforcement.

Literature Review

Drugs and Crime

Drug users, specifically heavy users, are extremely likely to commit crimes.

Depending on the city in which they reside, between 43-79% of male arrestees and between 33-82% of female arrestees tested positive by urinalysis for at least one illicit drug at the time of their offenses (National Institute of Justice, 1999). Additionally, more than one-half of all male arrestees (54%) and slightly less than one-half of female arrestees (43%) reported drinking alcohol in the 72 hours prior to their arrests (National

Institute of Justice, 1999). Twenty-two percent of males and 16% of females reported being under the influence of alcohol at the time of their offenses. In 2004, 17% of state prisoners and 18% of federal inmates said they committed their current offenses to obtain money for drugs (Mumola & Karberg, 2006). Additionally, 60% of convicted jail inmates admitted to using drugs or alcohol at the time of their offenses and 83% of state prison inmates reported a history of regular drug use, with 52% of these individuals reporting use at the time of their offenses (Mumola, 1999). Half of all State (53%) and Federal

(45%) inmates met the DSM-IV diagnostic criteria for chemical dependence (Mumola & POSITIVE REINFORCEMENT IN DRUG COURTS 6

Karberg, 2006). Although many offenders have drug abuse problems that are associated with their criminal lifestyles, only a small number of them receive treatment during their involvement with the criminal justice system. Only about 13-14% of drug and alcohol- using jail inmates participated in some form of substance abuse treatment since their admissions to jail, and only about 15% of state prisoners reported participation in any treatment since their admissions to prison (Mumola, 1999). In addition, individual help- seeking beliefs, health service policies, and community provider and criminal justice biases often interfered with this population having access to services (Wolff, 1998).

Strategies to Respond to Drugs and Crime

Drug policy in the United States has historically treated drug abuse as being a public safety concern, requiring punitive correctional measures, or as a public health concern, requiring treatment approaches. Unfortunately, both of these single-minded approaches have failed to rehabilitate drug abusing offenders or reduce criminal recidivism (Marlowe, 2002). The first public safety approach was to put drug abusers in prison. Drug abuse is illegal and drug abusers commit a disproportionate amount of crime and violence, so the natural response was to keep the public safe and confine these individuals in prison (Marlowe, 2002). However, incarceration has provided little benefit in terms of rehabilitating offenders and reducing recidivism. Without additional treatment, 55% of all offenders recidivate within three years of their release from prison, with even higher rates of recidivism among drug-abusing offenders (Marlowe, 2002).

One half of drug abusers recidivate within 18 months of release from prison, and about

70% recidivate within three years of release (Marlowe, 2002). In regard to drug use, about 85% of drug-abusing offenders relapse within one year of release from prison and POSITIVE REINFORCEMENT IN DRUG COURTS 7 about 95% relapse within three years. Therefore, it is clear that imprisonment does not effectively reduce drug use or criminal recidivism.

A second approach to combat drug use and criminal recidivism combined public safety and public health concerns by providing drug-abusing offenders with treatment while in prison. However, evidence suggests that prison drug rehabilitation programs have a small impact on criminal recidivism and little to no impact on reducing drug use

(Marlowe, 2002). Reviews of many prison drug rehabilitation programs reveal about a 10 percentage point reduction in recidivism (from 55% to 45%). Some “exemplary” prison treatment programs reported reducing recidivism by up to 25-30 percentage points, but they utilize professionally trained staff, serve high risk offenders, offer structured behavioral or cognitive-behavioral treatments, and focus on specific factors that affect their risks for recidivism (i.e. antisocial attitudes, impulsivity, sensation-seeking behaviors, and negative peer group associations) (Marlowe, 2002). Unfortunately, very few correctional programs (10-20%) come even close to fulfilling these “exemplary” program criteria, and fewer than 25% of drug-abusing inmates ever receive any in-prison drug or alcohol treatment (Marlowe, 2002). Additionally, in regard to reducing drug use, prison drug treatment programs have little effect. Long term studies show that parolees who attended substance abuse treatment while in prison, without follow-up care after prison, relapsed to drug use at the same rate as parolees who received no prison substance abuse treatment (Martin, Butzin, Saum, & Inciardi, 1999). Therefore, imprisonment combined with substance abuse treatment may result in a small reduction in criminal recidivism, but likely will not significantly reduce drug use, which makes it an inefficient method for rehabilitating drug-abusing offenders. POSITIVE REINFORCEMENT IN DRUG COURTS 8

A third approach to treating drug use among drug-abusing criminal offenders and preventing criminal recidivism involved civil commitment. Drug-abusing offenders were civilly committed to long-term residential treatment in isolated settings, instead of prison.

This method protected the public by confining and segregating these individuals, increased offenders’ access to treatment, and decreased the costs associated with imprisonment. Civil commitment programs in the United States date back to the 1930s and 1960s (Marlowe, 2002). The Public Health Service established what was known as federal “narcotics farms” in the mid-1930s in Kentucky and Texas (Platt, Widman, Lidz,

& Marlowe, 1998). They were rural, secure facilities where narcotic addicts were treated.

The addicts at these facilities were either voluntarily treated or involuntarily committed after a federal conviction, for up to a year of residential substance abuse treatment, followed by long-term community-based after care. Parole supervision was included, if appropriate (Platt et al., 1998). Results from these programs show that about 70% of voluntary patients exited the program prematurely and about 90% of all patients relapsed within one to two years (Platt et al., 1998). Patients who were mandated to participate in the program stayed in treatment longer and had slightly better outcomes, but overall, the program produced very poor outcomes (Platt et al., 1998).

Clearly, these three public safety-focused approaches to addressing drug-use in criminal offenders have been unsuccessful in reducing drug use or criminal recidivism.

Therefore, it was thought that a correctional approach may not be appropriate. To try a different approach, drug abuse or dependence was viewed as a “disease” that required focused treatment, not confinement or punishment, and offenders with drug abuse problems were referred only to treatment where they could be helped (Marlowe, 2002). POSITIVE REINFORCEMENT IN DRUG COURTS 9

However, without mandating offenders to treatment, about 90% of drug abusers drop out of treatment in less than 12 months (Marlowe, 2002). Research suggests that 12 months of treatment may be the minimum threshold for observing meaningful reductions in drug use; therefore, because drug abusers typically drop out before that point, substance abuse treatment, by itself, does not seem to modify offenders’ behaviors effectively (Marlowe,

2002).

Overall, it is clear that the harsh penalties the law imposes for drug offenders do not result in reduced rates of drug arrests (Marlowe, 2002). Instead, the harsh penalties often result in an increase of addicts in the criminal justice system (Blumstein and Beck,

1999). It appears that the only type of approach that has ever been somewhat successful and consistent in addressing the relationship between drug use and crime has been an integrated public health/public safety strategy that combines community based substance abuse treatment with criminal justice supervision. Therefore, what if the criminal justice system continuously monitored criminal offenders’ participation in community counseling, received progress reports from case managers, took random urine samples to confirm drug abstinence, and provided immediate consequences associated with clients’ performances in treatment? This approach would facilitate offenders’ access to treatment, reduce prison costs, and likely reduce drug use and criminal recidivism (Marlowe, 2002).

The Development and Characteristics of Drug Courts

Therefore, in 1989, courts in Dade County, Florida developed a system that is currently used nationwide and addresses both the underlying drug abuse problems of offenders and criminal recidivism. Referred to as drug or treatment courts, this system involves diversion programs that redirect drug offenders into treatment. Drug courts POSITIVE REINFORCEMENT IN DRUG COURTS 10 identify drug-abusing offenders early in the adjudication process and offer them participation in a unique system that includes immediate access to treatment under the direct and close supervision of the judge, instead of a stay in prison (Burdon et al., 2001).

Early drug courts were developed to serve adults charged with drug-related crimes. Participants in adult drug courts have a moderate to severe substance use disorder and are charged with a drug-related offense, such as possession or sale of a controlled substance or theft or forgery to support a drug addiction. Most drug court programs are designed to run for 12 to 24 months (Burdon et al., 2001). To be discharged successfully, participants must complete a regimen of substance use disorder treatment, demonstrate continued abstinence from illicit drugs and alcohol, remain arrest free, obey curfews, obtain employment and participate in other social activities, pay any applicable fines, and complete community service or apologize to their victims (Burdon et al., 2001).

There are ten key components to the drug court model that represent how a drug court is operationally and conceptually different from traditional criminal courts. These key components are: 1) Integration of alcohol and other drug treatment services with justice system case processing; 2) a non-adversarial approach, prosecution, and defense counsel that promote public safety while protecting participants’ due process rights; 3) early identification and prompt placement in the drug court program; 4) access to a continuum of alcohol, drug, and other related treatment and rehabilitation services; 5) abstinence monitoring by frequent alcohol and drug testing; 6) a coordinated strategy that governs drug court responses to participants’ compliance and noncompliance via graduated sanctions and rewards; 7) ongoing judicial interaction with each participant; 8) monitoring and evaluation of the achievement of program goals to gauge effectiveness; 9) POSITIVE REINFORCEMENT IN DRUG COURTS 11 interdisciplinary education to promote effective drug court planning, implementation, and operations; and 10) forging partnerships among drug courts, public agencies, and community-based organizations (U.S. Department of Justice, 1997).

Of these ten key components, frequent status hearings are one of the most effective aspects of drug courts (Marlowe, 2006). Specifically, the ongoing judicial interaction with each participant makes status hearings most effective (Marlowe, 2006).

In the drug court system, judicial involvement means not only sentencing offenders to varying levels of community supervision, but also continuously monitoring participants’ progress and altering dispositions according to participants’ compliance. This is done via ongoing judicial status hearings, which typically occur every 4-6 weeks.

During these hearings, the judge has the opportunity to review a client’s progress in treatment, which involves looking at records of attendance, abstinence, and general adherence to program rules (Festinger et al., 2002). After reviewing a client’s progress, the judge rewards each client for achievements or sanctions for failing to meet program requirements. Rewards include verbal praise, reduced supervision requirements, or gifts.

Sanctions include transfer to a more intensive level of care or punitive sanctions, such as writing assignments, community service, and brief jail detentions. These consequences are delivered in open court after the drug court team has met and reviewed each case to reach a decision about the next appropriate course of action (Burdon et al., 2001).

Considerable attention has been given to the symbolic impact of the “black robe”.

It is thought that the “black robe” makes the role of the judge in status hearings central to the efficacy of drug courts (Satel, 1998). Defendants often credit at least part of their success in drug courts to the fact that a powerful individual, like a judge, took a personal POSITIVE REINFORCEMENT IN DRUG COURTS 12 interest in him or her. (Goldkamp, White, & Robinson, 2002). This symbolic influence of the judge is supported by the theory of procedural justice, which states that individuals are more likely to perceive a decision as being correct and appropriate if they believe that fair procedures were involved in reaching that decision (Sydeman, Cascardi, Poythress, &

Ritterband, 1997). Therefore, criminal defendants will be more likely to accept an adverse decision if they feel they had a fair opportunity to voice their positions, were treated similarly to people in similar circumstances, and were treated with respect and dignity (Tyler, 1994). Defendants often feel heard and believe that they are being treated fairly when their cases are handled by a judge, instead of a probation officer, because they often view judges as the symbols of justice and can openly see how judges interact with other clients from the program in court (Marlowe, 2006). Along with this unique approach, drug courts also provide personalized programs, diversion from criminal charges and incarceration, and cost savings.

Benefits of Drug Courts

Drug court treatment programs vary according to individual clinical needs.

Participants can receive substance use treatment, mental health treatment, family counseling, vocational counseling, educational assistance, housing assistance, and/or help obtaining medical or dental care (Marlowe, 2010). Additionally, some adult drug courts prevent participants from incurring a criminal record, if they successfully complete their programs. If so, their charges are withdrawn and the arrests are expunged from their records (Marlowe, 2010). Other types of drug courts offer the drug court program as a condition of probation or another criminal sentence. If participants successfully complete POSITIVE REINFORCEMENT IN DRUG COURTS 13 their programs in these settings, they can avoid incarceration and potentially reduce the length or conditions of their probations (Marlowe, 2010).

Drug courts significantly reduce drug use and crime, and save money. Drug court participants reported significantly less use of illegal drugs and heavy use of alcohol than those in typical prison situations (Marlowe, 2010). Drug courts also reduce post-program criminal recidivism for at least one to three years (Belenko, 1998), as seen by fewer re- arrests for new offenses and technical violations (Marlowe, 2010). Stevens and Taylor

(2003) found an 83% reduction in incarceration among drug court graduates, resulting in an annual savings of $18 million for the state of California. Therefore, drug courts can be highly cost-effective. They produce an average of $2.21 in direct benefits to the criminal justice system for every $1.00 invested, which is a 221% return on investment (Marlowe,

2010). Also, when Drug Courts targeted their services to the more serious, higher-risk offenders, the average return on investment was even higher, with an average of $3.36 in direct benefits for every $1.00 invested (Marlowe. 2010).

Overall, drug courts offer a new model as a response to the growing number of offenders with drug abuse problems who cycle through the criminal justice system without receiving any treatment (Burdon et al., 2001). They provide significantly more community supervision and substance abuse treatment for offenders than standard pre- trial supervision or probation programs (Festinger, Marlowe, Lee, Kirby, Bovasso, &

McLellan, 2002). Drug courts also retain clients in treatment significantly longer than pretrial supervision or probation programs, resulting in greater reductions in substance use, criminal recidivism, and unemployment (Belenko, 1998). POSITIVE REINFORCEMENT IN DRUG COURTS 14

Due to their extraordinary success, drug courts became increasingly popular in the

1990s and 2000s. Since their development in 1989, over 3,000 drug courts have emerged across the United States (U. S. Department of Justice, 2016). Marlowe, Hardin, and Fox

(2016) described the variants that have developed in drug courts. One of these types of variants is DUI courts; these serve individuals who are charged with multiple instances of driving under the influence (DUI) of drugs or alcohol. Some DUI courts also serve first- time DUI offenders with a high blood alcohol content (BAC) at arrest or with other risk factors for impaired driving in the future. Juvenile drug courts are another variant to the traditional adult drug court model. Juvenile drug courts serve teens charged with delinquency offenses associated with a moderate to severe substance use disorder or co- occurring mental illness. The family drug court is another type of drug court that serves parents or guardians with substance use problems, who are facing allegations of child abuse or neglect, caused by their moderate to severe substance use disorders. Reentry drug courts serve parolees or other individuals, released conditionally from jail or prison, who have a moderate to severe substance use disorder. Campus drug courts, another variant to adult drug courts, serve college students who are facing suspension or expulsion for substance related honor code violations. Tribal healing in wellness drug courts apply traditional Native American healing practices to individuals charged with substance related violations of tribal laws. Co-occurring disorders courts serve individuals charged with criminal or juvenile offenses, who are also diagnosed with a moderate to severe substance use disorder and a serious mental illness. There are also federal reentry drug courts; these serve individuals with substance use disorders, who are also on supervised release form the U.S. Bureau of Prisons. Veteran treatment courts POSITIVE REINFORCEMENT IN DRUG COURTS 15 serve military veterans or active-duty military personnel, who are charged with crimes related to substance use disorders and/or serious mental illnesses. The immersion of other types of drug courts and the overall success of the standard drug court model can be explained by the adherence to three principles.

Reasons for Success: The Diversion Model, Therapeutic Jurisprudence, and

Behavioral Principles

The first principle that may contribute to their success, making drug courts an improvement in thinking about dealing with drug offenders, is their focus on diversion.

Drug courts adopt the diversion model, which results in prison-bound, non-violent drug offenders being diverted from criminal justice settings to community-based treatment

(Broner, Nguyen, Swern, & Goldfinger, 2003). Research has demonstrated that incarceration is not effective at reducing drug use or criminal recidivism (Marlowe,

2002). The diversion model offers offenders the opportunity to participate in judicially supervised treatment (Marlowe, 2002).

The second principle that makes drug courts effective, potentially contributing to their success, is “therapeutic jurisprudence.” Overall, rather than utilizing traditional jurisprudence, drug courts include therapeutic jurisprudence, a philosophy that promotes an attempt to monitor the impact on the emotional life and psychological well-being of individuals affected by decisions of the justice system (Winick, 1997). The goal is to utilize the work of the social sciences in order to examine the therapeutic or non- therapeutic effect of decisions by courts and justice agencies. Following this principle, the drug court judge, defense attorney, and prosecutor work together to improve client outcomes (Winick, 1997). As such, they take on the role of a therapist, to some degree. POSITIVE REINFORCEMENT IN DRUG COURTS 16

As a result of the diversion approach and therapeutic jurisprudence, the primary objective of drug courts is to reduce drug abuse and criminal recidivism in order to improve public safety and public health. However, there is one other principle associated with drug courts that makes them so effective in achieving this objective: adherence to strict principles of behavioral modification (Festinger et al., 2002).

Drug Courts’ Adherence to Behavioral Principles

The drug court model is a behavioral model that provides clear expectations and graduated sanctions and rewards for infractions and accomplishments. Drug courts heavily utilize the threat of punishment aspects of behavioral interventions, via graduated sanctions if participants do not adhere to the rules and expectations; however, they do not often use positive or negative reinforcement for appropriate behaviors (Marlowe &

Wong, 2008). The use of negative reinforcement is the most commonly administered form of reinforcement (Marlowe & Wong, 2008). Despite its popularity, negative reinforcement is not beneficial because it involves reductions in participants’ treatment or supervisory obligations. For example, the use of negative reinforcement may permit participants to attend treatment sessions less regularly, deliver urinalysis less frequently, or have briefer court appearances as a result of their good behavior. However, these drug court components that participants tend to view as cumbersome are crucial to the effectiveness of the program. Unfortunately, drug courts tend to rely more often on negative reinforcement than on positive reinforcement for promoting behavior change

(Marlowe & Wong, 2008). Positive reinforcement has been shown to be more effective in maintaining long term behavior change, for all types of people with problematic behaviors, than negative reinforcement (Martin & Pear, 2014). Unfortunately, sanctions POSITIVE REINFORCEMENT IN DRUG COURTS 17 are more readily available than rewards within drug courts (Marlowe & Wong, 2008).

This is problematic because positive reinforcement is more effective than punishment in changing behaviors (Martin & Pear, 2014).

Positive reinforcement (rewards) is a major component of contingency management (CM), a specific behavioral intervention. CM is evidence based and promotes behavior change through systematic, positive reinforcement of desired behaviors and withholding reinforcement for undesired behaviors (Higgins & Petry,

1999). CM has been shown to be very effective in treating substance use disorders

(Chambless & Ollendick, 2001). It is more successful in treating substance use disorders than standard case management (Higgins & Petry, 1999). In order to understand how contingency management principles are effective in treating substance use disorders, it is important to examine how the contingency management approach to substance abuse treatment has evolved. There are two historical roots for the development of contingency management for drug abuse: the operant behavior pharmacology conceptualization of drug abuse and drug self-administration and the behavioral analysis and treatment of alcoholism (Bigelow & Silverman, 1999). The behavioral pharmacology theme developed in animal laboratories as a basic behavioral strategy for developing experimental models of substance abuse. The behavior analysis and treatment theme developed with the application of behavioral science principles to the understanding and changing of alcohol abuse and dependence. Both of these approaches have roots in operant psychology. The essence of operant psychology is the belief that behavior is learned and reinforced by interaction with environmental contingencies. Operant psychology principles support the idea that even complex human behavior is open to POSITIVE REINFORCEMENT IN DRUG COURTS 18 scientific study and analysis, and behavior can be changed by changing its consequences

(Bigelow & Silverman, 1999).

Between the 1930s and 1940s, reinforcement was capable of changing or shaping a wide range of behaviors in a diverse range of organisms, including humans (Dews,

1959; Ferster & Skinner, 1957; Skinner, 1938). Over several decades, research has shown that reinforcement can exert robust control over behavior. Research has also indicated that rates and patterns of responding have changed abruptly as a function of changes in the schedule of reinforcement, meaning how often rewards/reinforcers are provided

(Ferster & Skinner, 1957). Specifically, behavior was found to be very sensitive to the rate (Catania, 1966), immediacy (Pierce, Hangford, & Zimmerman, 1972), and magnitude (Hodos & Kalman, 1963) of reinforcement. Operant behaviors could be reduced or eliminated relatively easily through the contingent application of punishment

(aversive stimuli) (Azrin, & Holz, 1966), by reinforcing alternative incompatible behaviors (Catania, 1966), by discontinuing reinforcement (extinction) (Ferster &

Skinner, 1957), or by combining these variables.

Operant psychology views substance use disorders as instances of reinforced operant behavior that are controlled by environmental consequences (i.e., behavioral contingencies). Under this operant behavior conceptualization, drug self-administration behavior is viewed as the core of substance use disorders. Abused substances serve as positive reinforcers that strengthen and maintain drug self-administration behavior. Drug use behavior becomes abusive when it becomes excessively controlled by the reinforcing effects of drugs and inadequately controlled by the potential reinforcing effects of other activities. This view supports the ability of drugs of abuse to reinforce behavior as POSITIVE REINFORCEMENT IN DRUG COURTS 19 biologically normal. Drug abuse behavior disorders result from inadequate environmental contingencies of reinforcement, rather than from individuals’ personalities and characteristics (Bigelow & Silverman, 1999). Therefore, treatment must focus on bringing behavior under the control of alternative behavioral contingencies that selectively reinforce and promote drug abstinence or other non-drug related prosocial behaviors (Bigelow, Brooner, & Silverman, 1997). Overall, this operant behavior perspective does not support the idea that drug reinforcement is the only mechanism by which substance abuse disorders develop. It recognizes that vulnerability factors

(biological, environmental, and behavioral) can play a role in development. However, one of the benefits to this perspective is that it suggests mechanisms for intervention, altering behavioral contingencies, do work, regardless of specific etiologic factors

(Bigelow & Silverman, 1999).

Early research done in laboratories supports the operant behavioral conceptualization of drug abuse. Specifically, laboratory research shows that drugs can serve as reinforcers to maintain drug seeking and drug self-administration in animal subjects. Initial studies demonstrated that chimpanzees (Spragg, 1940), rats (Headlee,

Coppock, & Nichols, 1955), and rhesus monkeys (Thompson & Schuster, 1964), who were physiologically morphine dependent, would self-administer morphine. This suggests that morphine served as a reinforcer in these laboratory animals. Other studies showed that even non-physiologically dependent animals (rats) were reinforced by intravenous injections of cocaine (Pickens & Harris, 1968). These results support the relationship between drugs and their reinforcement effects. POSITIVE REINFORCEMENT IN DRUG COURTS 20

Early research on operant conditioning and treatment of drug abuse in humans also supports the operant behavior conceptualization of drug abuse. Cohen, Liebson,

Faillace, and Allen (1971) conducted a study that involved five male alcoholic adults living in a residential research unit. Throughout the study, these participants were allowed to drink up to 24 ounces of 95-proof ethanol on weekdays. During weeks 1, 3, and 5, a contingency was put in place, which allowed participants to live in an “enriched” environmental condition, as long as they did not drink more than 5 ounces of ethanol a day. If they drank more than 5 ounces of ethanol in a day, they were removed from the

“enriched” environment and placed in an “impoverished” environment. The “enriched” environment allowed access to a variety or privileges, including: a recreation room, the opportunity to work for pay, access to preferred foods and non-alcoholic drinks, and the opportunity to have visitors. None of these privileges was available in the

“impoverished” environment. During weeks 2 and 4, participants remained in the

“impoverished” environment, regardless of ethanol intake. Results from this study showed that the contingency produced significant control over drinking behaviors.

Specifically, during weeks 1, 3, and 5, all participants drank 5 ounces or less of ethanol per day. In contrast, during weeks 2 and 4, all participants routinely drank more than 5 ounces of ethanol per day, with most participants reaching the daily maximum amount allowed, which was 24 ounces of ethanol. Therefore, the positive reinforcer (the

“enriched” environment) effectively motivated participants to continue to drink less alcohol in order to continue to access the positive reinforcer. This shows that the use of non-drug positive reinforcement, a CM technique, can effectively change and reduce drinking behaviors. POSITIVE REINFORCEMENT IN DRUG COURTS 21

Research also shows improved outcomes when CM techniques are applied to clients who are dependent upon marijuana (Budney, Higgins, Radonovich, & Novy,

2000), cigarettes (Roll, Higgins, & Badger, 1996), alcohol (Petry, Martin, Cooney, &

Kranzler, 2000), opioids (Bickel, Amass, Higgins, Badger, & Esch, 1997), benzodiazepines (Stitzer, Iguchi, & Felch, 1992), and multiple drugs (Silverman et al.,

1996). Overall, early research in animals and humans provides clear evidence for drug abuse as an operant behavior that is maintained and changeable by its consequences. This shows that operant behavioral techniques, such as CM, are effective in treating substance use disorders.

Voucher-based CM

Recently, the CM intervention that has gained the most frequent attention is one in which patients earn vouchers that are exchangeable for retail items, contingent on recent drug abstinence. This treatment method was originally developed as a novel method to manage cocaine dependence in outpatient settings (Higgins et al., 1993). In their study, Higgins et al. (1993) used vouchers, combined with intensive counseling based on a community reinforcement approach (CRA). They compared CRA plus vouchers with standard care. The voucher program was implemented around a fixed schedule of urine-toxicology monitoring. If participants presented with cocaine negative specimens, they earned points that were recorded on vouchers provided to them. Points began at a value of $2.50 and increased with each consecutive negative urine test result.

A cocaine positive result or failure to provide a urine sample reset the voucher value back to the initial low value ($2.50), from which participants could work to try to increase it again. No money was ever given to participants. Instead, point values were used to POSITIVE REINFORCEMENT IN DRUG COURTS 22 purchase retail items. Clinical staff made all the purchases. Across the 12-week program, maximum earnings possible were $997.50 in purchasing power. Results showed that the average earning was approximately $600.00. Results also showed that participants who were receiving standard care either dropped out of treatment or continued using cocaine; however, the majority of those assigned to CRA plus vouchers abstained from cocaine use (Higgins et al., 1993). Further research showed that overall, in 16 controlled studies examining the efficacy of voucher-based CM interventions for increasing cocaine abstinence, 15 of 16 studies (94%) demonstrated significant increases in cocaine abstinence (Higgins, Heil, & Lussier, 2004). These results support the effectiveness of voucher-based CM techniques in initiating cocaine abstinence. Research also shows that voucher-based CM more effectively initiates cocaine abstinence than vouchers that are delivered non-contingently or not at all (Kirby, Marlowe, Festinger, Lamb, & Platt,

1998).

Voucher-based CM interventions have also been effective in treating addiction in opiate-dependent outpatients. In three voucher-based CM trials conducted with patients enrolled in methadone-maintenance treatment (Preston, Umbricht, & Epstein, 2000,

2002; Silverman et al., 1996) and in two trials conducted with patients undergoing methadone (Robles, Stitzer, Strain, Bigelow, & Silverman, 2002) or buprenorphine

(Bickel, Amass, Higgins, Badger, & Esch, 1997) detoxification, opiate abstinence significantly increased in the voucher conditions, compared with non-voucher conditions.

In two trials, effects of vouchers were not dissociated from other interventions, but in each of the other trials, the increases in abstinence were directly due to the vouchers POSITIVE REINFORCEMENT IN DRUG COURTS 23

(Bickel et al., 1997; Preston et al., 2002). These results support the use of voucher-based

CM interventions in treating opiate abuse.

Voucher based CM interventions have also been successful in increasing alcohol abstinence. Petry et al. (2000) had 42 alcohol-dependent veterans randomly assigned to receive standard treatment or standard treatment plus CM. The CM condition included the chance to win prizes for submitting negative Breathalyzer samples and completing steps towards treatment goals. Specifically, patients with negative Breathalyzer samples earned opportunities to draw slips of paper, which had values listed on them ranging from no value to $100, from a fishbowl. Slips of paper with monetary value were exchanged for retail items that were kept on site at the clinic. Most of the slips of paper contained no or low monetary values. Regardless, results showed that patients in the standard treatment with CM condition increased treatment retention and alcohol abstinence, compared with participants in the standard treatment only condition. These results support the use of CM techniques to increase alcohol abstinence and participation in alcohol abuse treatments.

Voucher-based CM interventions have also been effective in increasing marijuana abstinence. Budney et al., (2000) conducted a study in which 60 patients in outpatient treatment for marijuana dependence were randomly assigned to one of three conditions: motivational enhancement (M), M plus behavioral coping skills therapy (MBT), or MBT plus voucher-based incentives (MBTV). In the voucher-based incentives condition, participants earned vouchers, exchangeable for retail items, contingent on their submitting cannabinoid-negative urine samples. Results showed that individuals in the

MBTV condition showed significantly greater durations of marijuana abstinence during treatment than the MBT and M conditions. A greater percentage of participants in the POSITIVE REINFORCEMENT IN DRUG COURTS 24

MBTV condition, compared with the MBT and M conditions, were also abstinent from marijuana at the end of the treatment. This supports the effectiveness of voucher-based

CM interventions in treating marijuana dependency. Voucher-based CM techniques are effective in producing substance use changes in other settings, too.

Voucher-based CM in Forensic Settings

In a study by Marlowe, Festinger, Dugosh, Arabia, and Kirby (2008), the authors evaluated a CM program in a drug court. Gift certificates for compliance were delivered at 4-6 week intervals. Participants in one condition earned gift certificates that escalated by $5 increments. Participants in a second condition earned higher magnitude gift certificates, but the density of reinforcement was gradually decreased. No main effects of

CM were detected, meaning that, overall, the addition of a CM program did not improve outcomes for participants in a felony pre-adjudication drug court. However, this appeared to be due to a ceiling effect from the intensive contingencies already delivered in the drug court and the low density of reinforcement (Marlowe et al., 2008). The authors suggest that the professionals in drug courts need to be reminded of the importance of using positive reinforcement in their work, due to the many studies that support the effectiveness of using positive reinforcement/CM techniques to treat substance use disorders. The authors also suggest, that in their study that longer delays before reinforcement result in reduced efficacy. Therefore, they state that CM techniques would have probably been more effective in their study had they increased the immediacy and density of the reinforcements.

As can be seen, decades of research support the fact that reinforcement processes play a central role in developing, maintaining, and recovering from substance use POSITIVE REINFORCEMENT IN DRUG COURTS 25 disorders. Additionally, research supports the fact that reinforcement principles can be effectively applied to improve clinical outcomes among individuals with substance use disorders. Specifically, CM techniques have been very effective in increasing abstinence among individuals who suffer from a variety of substance use disorders. Voucher-based

CM, especially, has been one of the most effective forms of CM in treating substance use disorders. There are also many other advantages to using a voucher-based CM system, besides their effectiveness in increasing treatment retention and drug abstinence. First, it allows for individual preferences, and clients can spend their vouchers on almost any item they want. Common items include: restaurant gift certificates, clothing, haircuts, sports equipment, movie theater tickets, and movies. Additionally, providing vouchers is better than providing cash because this greatly reduce the risk of clients spending their incentives on drugs (Petry & Simcic, 2002).

The drug court model should incorporate positive reinforcement techniques in order to further improve effectiveness in reducing the problems encountered by the criminal justice system in dealing with substance-abusing offenders. However, despite its strongly supported effectiveness and relative simplicity, many clinical practices and substance abuse programs, including drug courts, have not adopted CM techniques (Petry

& Simcic, 2002). McGovern, Fox, Xie, and Drake (2004) found that treatment providers have reported that CM interventions were used in their programs only 11-25% of the time. Additionally, only 9% of the counselors that were surveyed reported that they were just beginning to use CM techniques (McGovern et al., 2004).

POSITIVE REINFORCEMENT IN DRUG COURTS 26

Barriers to Using CM

Treatment Programs

There are a few reasons why programs may not use CM. First, programs may not be aware of CM. However, this is unlikely because 74-82% of SUD counselors and program administrators have enough knowledge, regarding CM, to be aware of its effectiveness and acceptability (Bride, Abraham, & Roman, 2011). Another reason CM may not be utilized is the perceived acceptability of CM. There continue to be negative attitudes toward certain aspects of CM, especially the provision of tangible incentives

(Kirby, Benishek, Dugosh, & Kerwin, 2006). In their study, Kirby et al. (2006) surveyed

383 treatment providers across the United States about moral or ethical objections, negative side effects, practicality, limitations, and opinions of tangible and social CM interventions. Results showed that a surprising number of providers held positive beliefs toward the use of CM interventions (Kirby et al., 2006). However, only half of their sample of providers stated that they would be in favor of adding a tangible CM intervention to their treatment programs. The authors suggest that this is probably due to the fact that even though providers gave objections to tangible reinforcers, they had just as many positive beliefs about using other forms of CM (i.e. social reinforcers). Overall, the three most common objections to using CM techniques were: cost, inability to address underlying issues, and targeting multiple behaviors (Kirby et al., 2006).

In regard to cost, the majority of treatment providers indicated that their treatment programs could not afford a CM intervention that cost $50-$150 per client per month; this is the amount that research supports as being effective (Petry & Martin, 2002).

Research also shows that patients earn an average of $600 worth of goods in most CM POSITIVE REINFORCEMENT IN DRUG COURTS 27 programs, which is an amount that is often prohibitive for many treatment programs

(Petry & Simcic, 2002). Concerns about other costs, such as the labor needed to conduct weekly urinalysis, were not as prevalent as concerns about the costs of the tangible reinforcers themselves (Kirby et al., 2006). However, many providers endorsed the idea that weekly urinalysis for every client seemed impractical, and research shows that conducting urinalysis less than 3 times per week greatly reduces the effectiveness of the

CM intervention (Griffith, Rowan-Szal, Roark, & Simpson, 2000).

In regard to the second most prominent objection, “inability to address underlying issues” (for example: depression, trauma, and/or other environmental, emotional, and psychological stressors), few providers endorsed this objection as a barrier to disseminating incentives. Providers believed that failure to address underlying issues did not mean the incentives were useless (Kirby et al., 2006). The third most prominent objection that providers endorsed was “targeting multiple behaviors”. This means that providers felt it was wrong to reward clients for achieving one treatment goal (i.e. providing clean urine samples) when they were not fulfilling other treatment goals, too

(i.e. attending treatment regularly). Therefore, treatment providers might be more inclined to use CM interventions if they targeted multiple behaviors instead of focusing on only one behavior (Kirby et al., 2006). Research supports the idea that CM interventions are more effective when they target one drug use behavior rather than multiple drug use behaviors (Griffith et al., 2000), but it is not clear that targeting one drug use behavior and other treatment behaviors (i.e. attendance, completion of treatment goals) reduces effectiveness. POSITIVE REINFORCEMENT IN DRUG COURTS 28

Finally, the results of study by Kirby et al. (2006), revealed two additional objections to using tangible CM interventions. The first was negative side effects. This means that providers were concerned that using tangible reinforcers would spark arguments and jealousy among clients, damage effects to the treatment process, or undermine internal motivation (Kirby et al., 2006). The second objection that a few treatment providers endorsed was a philosophical objection, that tangible reinforcers are a bribe (Kirby et al., 2006). However, this may be due to a lack of understanding of contingency management or a lack of awareness regarding the validity of behavior modification.

In regard to social reinforcers, results showed that treatment providers endorsed many of the same objections as they had for tangible reinforcers. However, there were fewer objections to social reinforcers than for tangible reinforcers (Kirby et al., 2006).

Unfortunately, though, social reinforcers, which involve clients being verbally praised and recognized for their accomplishments by the treatment program employees and clinicians, do not have strong empirical support (Kirby et al., 2006). However, when social reinforcers are delivered by important people in the client’s life, such as family and friends, they have good empirical support, but are not widely used in treatment programs

(Kirby et al., 2006). This is likely because providers would have to spend time training clients’ families and friends on how and when to deliver social reinforcers.

These results are crucial to understanding how treatment providers view the use of

CM interventions in their treatment programs. With this information, researchers can be better prepared when suggesting the use of CM interventions and ways to implement CM interventions in treatment programs. For example, finding a way to reduce the cost of POSITIVE REINFORCEMENT IN DRUG COURTS 29 reinforcers would probably greatly increase the chances of treatment programs utilizing

CM interventions/positive reinforcement. Petry and Simcic (2002) suggest ways to reduce the costs of CM procedures. Specifically, they highlighted the notion that an intermittent schedule of reinforcement can be effective in reducing cost.

An intermittent schedule of reinforcement would provide tangible reinforcers for only a proportion of the target behaviors. In the aforementioned study conducted by Petry et al. (2000), alcohol-dependent clients earned the chance to draw from a bowl of prizes, of varying amounts, for submitting negative breath-alcohol samples and completing treatment goals. The prize amounts ranged from $1.00 to $100, but the chances of drawing a $1 prize were one in two, but the chances of drawing a $100 prize were one in

250. This intermittent schedule of reinforcement system is less expensive because only a proportion of behaviors are reinforced with a prize, and the average cost per client was less than $200, total (Petry et al., 2000). Therefore, this system retains many of the important features of the voucher-based positive reinforcement system, but also reduces overall costs. These results provide insight into potential barriers to using positive reinforcement CM interventions in treatment settings, but all of these results explored the use of positive reinforcement only in community treatment programs. Therefore, it is important also to look at the beliefs and perceptions regarding the use of CM in justice settings.

Justice Settings

Murphy, Rhodes, and Taxman (2012) examined beliefs regarding the acceptability of CM in a justice setting. Specifically, they administered a survey, which included Kirby et al.’s (2006) Provider Survey of Incentives (PSI), to 186 judges, POSITIVE REINFORCEMENT IN DRUG COURTS 30 prosecutors, defenders, probation officers (POs), and treatment providers from the judiciary, U.S. Probation, Federal Defenders offices, U.S. Attorneys Offices, and treatment/counseling programs. Their survey was divided into two sections. The first sections assessed characteristics of the court district, respondents’ attitudes toward rehabilitation and punishment, degree of inter- and intra-agency collaboration, and attitudes towards incentives. It also included questions on respondents’ backgrounds

(education, position, social demographics, etc.). The second section of their survey investigated court operations, opinions on components of CM, and respondents’ degrees of familiarity with incentives.

Results showed a moderate to high level of acceptability for incentives and their use in treating substance abuse issues, which is similar to the results of Kirby et al.

(2006). Results also showed that respondents had high levels of knowledge about CM.

Participants’ specific responses to the PSI were similar to those found by Kirby et al.’s survey of community treatment providers. Interestingly, results also showed that gender significantly affected attitudes towards the use of incentives, with women having more positive attitudes towards the use of incentives than men (Murphy et al., 2012).

Additionally, age and education also influenced attitudes towards using incentives.

Participants older than 35 years and with more than a bachelor’s degree had more positive attitudes towards using tangible incentives than participants younger than 35 years, with only a bachelor’s degree. In regard to social incentives, participants younger than 35 years and with more than a bachelor’s degree had more positive attitudes towards using social reinforcers than participants older than 35 years and with only a bachelor’s POSITIVE REINFORCEMENT IN DRUG COURTS 31 degree (Murphy et al., 2012). However, results showed that, overall, there was equal support for tangible and social reinforcers.

These results provide insight into using positive reinforcement CM procedures in justice settings, but they do not specifically reflect the beliefs and perceptions of using positive reinforcement among adult, pre-trial drug court coordinators. Additionally,

Murphy et al. (2012) did not investigate the types of positive reinforcement, frequency of positive reinforcement, ways of implementing positive reinforcement, and consistency in using positive reinforcement in justice settings. Therefore, research that investigates these variables is needed in order to have a better understanding concerning not only if, but also how positive reinforcement is used in real-world, adult, pre-trial drug courts.

Purpose of Study:

Contingency management (CM), an evidence based practice that promotes behavior change through systematic positive reinforcement of desired behaviors with rewards, is effective in treating alcohol and drug abuse. Specifically, CM is an evidence- based practice that is more successful in treating substance use than standard case management (Higgins & Petry, 1999). However, regardless of this finding, many substance abuse programs fail to use CM in routine practice (Kirby, Benishek, Dugosh, &

Kerwin, 2006). The purpose of this study is to survey drug courts, across the country, about their uses, perceptions, and practices of positive reinforcement, a CM strategy.

Specifically, this survey-based, mixed methods study will assess (1) the frequency of the use of positive reinforcement, currently or in the past, (2) stakeholders’ beliefs about the use of positive reinforcement in their programs, (3) the forms of positive reinforcement POSITIVE REINFORCEMENT IN DRUG COURTS 32 currently being used, and (4) the ways in which they implement positive reinforcement into their programs.

Information from this survey will allow the researcher to determine the frequency of positive reinforcement use in drug courts, how positive reinforcement techniques are being implemented, and perceived success of using positive reinforcement. This study will also provide useful information regarding attitudes towards adopting positive reinforcement. This would provide policy makers with some information necessary to address potential barriers to the use of positive reinforcement in this setting. Information from this survey, regarding what forms of positive reinforcement drug courts use and how they implement those forms, will be beneficial because it will allow the researcher to advise drug courts of what forms of positive reinforcement are most effective and how they can best be implemented. This information will assist courts in implementing the most effective forms of positive reinforcement in the most efficient ways. This will hopefully result in an increased frequency and rate of recovery from drug dependence, among drug courts’ populations of criminal offenders. Participants for this study will be adult, pre-trial drug courts in the United States. Using online questionnaires, data will be collected from these drug courts nationwide. Qualitative and quantitative methods will be used to interpret results.

POSITIVE REINFORCEMENT IN DRUG COURTS 33

Research Question

How many drug courts, nationwide, are currently using positive reinforcement or have used this in the past; what are their beliefs about the use of positive reinforcement in drug courts; what forms of positive reinforcement are they using, and how are they implementing these forms of positive reinforcement?

POSITIVE REINFORCEMENT IN DRUG COURTS 34

Method

Design

This study utilized a qualitative survey design. The survey used open-ended, multiple choice, and Likert-type scale questions to ask drug courts about variables of interest. Kazdin (2003) stated that the main task of qualitative research is to “explicate the ways people in particular settings come to understand, account for, take action, and otherwise manage their day-to-day situations” (p.333). This study aimed to understand participants’ patterns of positive reinforcement use and beliefs and perceptions about its use in drug courts.

Participants

Attempts were made to recruit a voluntary (convenience) sample of 50 specific court coordinators from pre-trial adult drug courts across the country. Fifty individual state coordinators, listed on the National Association of Drug Court Professional’s

(NADCP) website, were contacted with the help of NADCP’s Chief of Training and

Research. Each coordinator was asked to identify additional court coordinators within his or her state, regarding further participation in the survey. This resulted in a final sample of 39 participants who were drug court coordinators from pre-trial/pre-sentencing drug courts in the United States of America. The drug court coordinators are individuals who manage all of the activities and procedures that occur during the drug court process and interact with the judge, defense attorney, and the prosecutor. The pre-trial drug courts that were examined in this study were located in rural and urban areas and included drug- abusing criminal offenders, males and females, ages 18 and up, who participated in a POSITIVE REINFORCEMENT IN DRUG COURTS 35 variety of non-violent or violent crimes. It is anticipated that these criminal offenders represented a variety of socioeconomic classes and races.

Inclusion and Exclusion Criteria

The sample included drug court coordinators from adult pre-trial drug courts in the United States of America that were identified on the National Association of Drug

Court Professionals (NADCP) website. There were no other exclusion criteria if the inclusion criteria were met. This study focused on adult pre-trial drug courts because that is the first step in analyzing the use of positive reinforcement in drug courts. Pre-trial adult drug courts generally represent the most traditional and most prevalent drug courts in the country (Marlowe, Hardin, & Fox, 2016).

Materials

One survey assessment was administered to each drug court coordinator in the sample as an explicit measure of each court’s use of positive reinforcement, appraisal of what each drug court’s perception is of positive reinforcement use in the program, the forms of positive reinforcement currently being used, and the ways in which each drug court implements positive reinforcement into the program. The survey was divided into three main sections. The first section asked, “Do you use positive reinforcement in your drug court?” If the respondent answered, “yes”, there were additional questions for him/her to answer. The first additional question was, “What type of reward/reinforcer do you give?” The respondent was then presented with an unlimited list of potential rewards/reinforcers to choose from. The respondent had the ability to check off each one he or she has used or currently uses. Then, the respondent was asked a series of additional POSITIVE REINFORCEMENT IN DRUG COURTS 36 questions for each reward/reinforcer he or she reported using. These additional questions included: When and how can a client earn this reward/reinforcer (i.e. for what behavior(s) and at what times)? Who delivers this reward/reinforcer?, and What is the value of this reward/reinforcer? After that section of questions, additional questions included: How long have you been providing rewards/reinforcers? What initiated or caused you to begin to implement rewards/reinforcers into your program? How are the rewards/reinforcers funded?

The second section of the survey assessed specific characteristics of the drug courts. This section asked about the types of criminal offenders that participated in the drug court, the numbers of judges, the average numbers of clients seen per year, the current numbers of clients in the program, the use of medication assisted treatment, when the court began, how long the court program is intended to run, and what the requirements are for graduation from the program. Questions in this section assessed the type of drug court (i.e. felony, misdemeanor, or both; violent and/or non-violent crimes; and drugs, DUI, or hybrid (drug/DUI).

The third section of the survey asked the specific court coordinators to give their appraisals of what their courts’ perceptions are of the use of positive reinforcement in their programs. This question allowed respondents to use a Likert-type scale (from 1-5) to answer how open they think their courts were to the use of positive reinforcement. A response of 1 represented not at all open; 2 represented somewhat not open; 3 represented neither for nor against the use of positive reinforcement; 4 represented somewhat open, and a response of 5 represented very much open. POSITIVE REINFORCEMENT IN DRUG COURTS 37

An expert panel convened, including an expert in drug courts and an expert in qualitative research, to examine readability, to determine if any items should be added, to determine if all of the items make sense, and to improve the clarity of the survey.

Following their review, all requested modifications were made before the survey was finalized and put into Survey Monkey.

Procedure

In order to recruit participants, the researcher contacted Carolyn Hardin,

NADCP’s Chief of Training and Research, and obtained permission to contact the 50 individual state coordinators listed on the NADCP website. After permission was received, the researcher contacted the state coordinators via email, informed them about the project, and asked them if they would be willing to distribute the survey to individual court coordinators in their states. If they agreed to participate, the researcher sent them the link to the survey and asked them to forward it to as many individual court coordinators as possible. It took participants a range of time to complete the survey, depending on how many reinforcers they endorsed using in their drug court programs.

Data were collected via SurveyMonkey, which is an online software that provides free, customizable surveys, as well as programs that include data analysis, sample selection, bias elimination, and data representation tools. Data were anonymous and stored confidentially on SurveyMonkey. Open-ended responses were coded for common themes/responses by two graduate students. Likert-type scale responses were analyzed by a frequency count. POSITIVE REINFORCEMENT IN DRUG COURTS 38

All participating drug court coordinators had the option to enter into a raffle for three $50 VISA gift cards. It is important to note that interested participants were provided with a link to be entered into the raffle, so that their contact information was separate from their survey responses.

POSITIVE REINFORCEMENT IN DRUG COURTS 39

Results

Analyses

Survey responses were analyzed using qualitative and descriptive methods.

Qualitative data analysis searches in order to describe general statements about relationships and themes present in the data. Specifically, directed content analysis was used to analyze the data. Content analysis is a flexible method of qualitative data analysis that can be used for the subjective interpretation of the content of text data through the systematic classification process of coding and identifying themes and patterns (Hsieh &

Shannon, 2005). Directed content analysis is used when the researcher has some theory that guides analysis. Initial codes may be generated, based on theory or using the language and meanings that have been previously used to understand the phenomenon.

Data can then be mined for any additional codes to be explained along with how the coded data fits with the theory. Interpretation is done within the context of theory and can contribute to theory refinement and/or extension (Hsieh & Shannon, 2005).

Survey response coding/categorizing was completed by the researcher and one other master’s level graduate student from the University of Pennsylvania. Coders were supervised by a licensed psychologist, who has expertise in qualitative research methodology. The researcher determined a list of codes/categories for each survey question and for each survey response into which it was to be categorized. The full response set was used to calculate reliability estimates for each question. Two coders were used to code each response into an appropriate category (the researcher, and an additional volunteer). Each reliability coder coded every valid response. Cohen’s Kappa was used to calculate an estimate of reliability. Kappa was utilized because it takes into POSITIVE REINFORCEMENT IN DRUG COURTS 40 account the possibility of the agreement of categories between coders occurring by chance. Disagreements in the reliability coding were resolved via random assignment of the response into one of the two possible categories that the coders had selected.

Adequate reliability was established because the minimum reliability estimate was at the recommended cutoff of .90 (k = .90), and the majority of questions displayed excellent reliability (M = .99, SD =.02). Finally, descriptive statistics, including frequencies, means, standard deviations, minimums, and maximums were provided for quantitative responses.

Demographic Information

Fifty core drug court coordinators, one from each state in the United States of

America, were sent this study’s survey. Those 50 state drug court coordinators contacted representatives in each of their states. As shown in the consort diagram, 84 participants went through the consent process, agreed to participate, and started this study’s survey.

There were two screening questions. Of the 84 participants that responded, 70 indicated that they were a drug court coordinator; 12 responded, indicating that they were not drug court coordinators, and two participants did not answer this question. Of the 84 participants, 39 reported that their courts are considered pre-trial/pre-sentencing; 29 participants reported that their courts are not pre-trial pre-sentencing, and 16 participants did not answer this question. This resulted in a final sample of 39 participants who are drug court coordinators from pre-trial/pre-sentencing drug courts in the United States of

America (See Figure 1).

As displayed in Table 1, participants were an average age of 47.20 years old (M =

47.20 years, SD = 11.07 years). The minimum age was 28 years old, and the maximum POSITIVE REINFORCEMENT IN DRUG COURTS 41 age was 70 years old. Participants worked for their drug court for an average of 71 months (almost 6 years) (M = 71.26 months/5.94 years, SD = 61.62 months/5.14 years).

The minimum amount of time a participant worked for his/her drug court was 3 months

(0.25 years), and the maximum was 218 months (18.17 years) (See Table 1). Participants were asked if any member of their families has a substance use disorder, and 13 participants responded yes; 14 participants responded no, and four participants preferred not to answer (See Table 2).

The thirty-nine participants represented 13 different states in the United States of

America. As displayed in Figure 2, of the 13 states, five states were from the West; three states were from the Midwest; four states were from the South, and one state was from the Northeast. Additionally, 12 participants/courts were from states in the West; 3 participants/courts were from the Midwest; 12 participants/courts were from the South, and 4 participants/courts were from the Northeast (See Figure 2). As seen in Table 3, participants also represented many different types of pre-trial/pre-sentencing drug courts.

Fifteen participants were from felony drug courts; three participants were from misdemeanor drug courts; 14 participants were from both felony and misdemeanor courts; 25 participants were from non-violent crimes courts; three participants were from both violent and non-violent crimes courts; 25 participants were from only drug courts;

12 participants were from DUI courts, and seven participants were from hybrid courts

(drugs and DUI). Seven participants reported being from “other” types of drug courts, with one from Serious and Persistent Mental Illness (SPMI) Diagnosis court, one from pre-sentencing/post-sentencing court, one from juvenile court, one from court with no POSITIVE REINFORCEMENT IN DRUG COURTS 42 prior charges of drug trafficking or violence, one from non-drug crimes committed primarily due to drug use, and one from a mental health court (See Table 3).

As seen in Table 4, participants reported being from courts with one (n = 31) or two (n = 4) judges in their drug court programs. The average number of participants in these drug courts was 53.73 clients (M = 53.73 clients, SD = 47.24 clients), with a minimum of 10 clients and a maximum of 170 clients. At the time of the survey, there was an average of 44.97 clients in the drug court programs (M = 44.97 clients, SD =

44.13 clients), with a minimum of one client and a maximum of 199 clients. Participants’ drug court programs run for an average of 15.20 months (M = 15.20 months, SD = 4.33 months), with a minimum of 8 months and a maximum of 27 months. Participants also reported that their drug courts had been operating for an average of 12.35 years (M =

12.35 years, SD = 6.91 years), with a minimum of 1 year and a maximum of 28.02 years

(See Table 4). Participants were also asked if they use pharmacological treatments in their drug court programs. Twenty-three courts responded yes, and eight courts responded no. If participants endorsed using pharmacological treatments, participants were asked about the types that they use. Twenty-one participants reported using

Suboxone; 18 participants reported using Naltrexone; 11 participants reported suing

Methadone; five participants reported using Antabuse/Disulfiram, and two participants reported using Vivitrol (See Table 5).

Participants were also asked about requirements to graduate the drug court programs. As seen in Table 6, 39 participants reported that in order to graduate, clients must complete treatment (e.g., completion of individualized cases plan, complete treatment, complete goals, complete all goals of each path, complete Moral Reconation POSITIVE REINFORCEMENT IN DRUG COURTS 43

Therapy (MRT), complete mental health counseling, complete Substance Use Disorder treatment plan objectives, complete substance abuse program, complete all program requirements, comply with treatment and supervision, complete all phases, completion of the year, go through each phase and treatment phase successfully, at least 3 months in final phase, program compliance, in compliance with treatment recommendations).

Twenty-three participants responded that continued abstinence is needed to graduate

(e.g., 90 days substance free, sobriety, be clean and sober for 90 days, minimum six months sobriety, 120 consecutive clean days, drug free, clean drug tests). Eleven participants endorsed the fact that fines must be paid (e.g., all fines paid, pay all drug court fees and court ordered restitution, pay all legal obligations related to charges, pay

$100 program fee, pay court costs in full, payment of all fees, pay all restitution if any owed). Three participants responded that the participant may have no charges (e.g., no pending charges, minimum 3 consecutive months without a violation, no other new charges); four participants reported completing community service (e.g., community service project, 100 hours of community service, 259 hours community service, 20 hours of community service); one participant responded a fundraising activity, and one participant responded leading a group session. Twenty-three participants reported that clients must complete self-sufficiency goals (e.g., gain a GED or high school diploma, gain a driver’s license, address child support, employed, had a stable job, stable housing, maintained job training, parenting, family support, registered to vote). Thirteen participants reported having a relapse prevention/continuing care plan (e.g., transitioned to another mental health agency, completed a relapse prevention plan, participated in IOP therapy, participated in weekly NA meetings, sober network, developed a continuing care POSITIVE REINFORCEMENT IN DRUG COURTS 44 plan, had monthly home visits, monthly office visits, completion of Pay It Forward program, obtained and working with a sponsor). Two participants reported that clients must write an apology letter, five participants reported completing a final essay or project, and five responses could not be determined/categorized (See Table 6).

Use of Positive Reinforcers

Of the 39 drug court coordinators who participated in this study, 37 reported that they use positive reinforcement/rewards in their drug courts, and two drug court coordinators reported that they do not (See Table 7). Of the 37 participants that endorsed using positive reinforcement, additional questions were asked to assess what positive reinforcers these courts use and how they use them.

Types of Reinforcers Used

Overall, there were nine different types of reinforcers endorsed, including tokens/coupons/vouchers, gift cards/gift certificates, food, tangible items, reductions in clients’ program responsibilities, money, verbal praise, certificates of accomplishment, and any “other” type of reinforcer.

Tokens/coupons/vouchers. The first type of reinforcer the survey asked about was tokens/coupons/vouchers. Of the 37 participants who endorsed using positive reinforcement, 20 reported using tokens/coupons/vouchers (that can be exchanged for prizes) as reinforcers/rewards in their drug court program (See Table 8). These drug court coordinators were asked when (at what time(s) during the program) can a client earn a token/coupon/voucher, and participants reported five categories of times. Specifically, eight participants reported that clients can earn a token/coupon/voucher at any time in POSITIVE REINFORCEMENT IN DRUG COURTS 45 their programs. Four participants reported that clients in their courts could earn a token/coupon/voucher in the first phase of their programs, but only after an initial period of 30-60 days. One participant reported that clients can earn this type of reinforcer weekly; one participant responded bi-weekly, and one participant responded, at graduation. One response could not be determined/categorized, and four participants did not answer this question (See Table 9).

Reinforced behaviors. Drug court coordinators were also asked about the type or kind of behaviors for which clients in their courts can earn a token/coupon/voucher.

Eleven participants reported that clients in their courts can earn this type of reinforcer for compliance with the program (e.g., meeting the terms of their case plan for the phase of the program that they are in, completing program requirements, and attending treatment and meetings). Three participants reported that clients can earn this type of reinforcer for not having any infractions; three participants responded for continued abstinence, and two participants responded for attending appointments. Five participants reported that clients can earn this type of reinforcer for prosocial behaviors (e.g., having a positive attitude, helping a peer, and completing community service). Two participants reported that clients can earn this type of reinforcer for phase advancements, and five participants responded for achieving milestones (e.g., getting their licenses back, gaining guardianship of their children, obtaining employment, getting a good GPA in school, and earning rewards, such as client of the month or voted most improved). Five responses could not be determined/categorized (See Table 10).

Reinforcer value, delivery, and history. Of the 20 participants who reported that their courts used tokens/coupons/vouchers, 10 participants reported that POSITIVE REINFORCEMENT IN DRUG COURTS 46 tokens/coupons/vouchers can be exchanged for some type of gift card (e.g., Walmart, fast food places, gas). Six participants reported that this type of reinforcer could be exchanged for entertainment (e.g., sporting events, movie tickets, theater events). Seven participants reported that tokens/coupons/vouchers could be exchanged for food (e.g., meals, fast food meals, candy, milkshakes), and one participant reported that tokens/coupons/vouchers could be exchanged for money. Eight participants reported that this type of reinforcer could be exchanged for reductions in program responsibilities (e.g., attend fewer meetings/therapy sessions, community service credit, fewer check ins, excused from class, a court pass, extended curfew, early dismissal from court). Four responses could not be determined/categorized (See Table 11).

Participants were also asked about the monetary value of tokens/coupons/vouchers; about who delivers the actual reinforcer, and for the length of time that their programs has been providing this type of reinforcer. One participant responded that the tokens had no value; five participants reported a value up to $5.00; six participants reported a value up to $10.00; five participants reported a value up to $25.00, and one participant reported a value greater than $50.00 (e.g., highest value has been over

$2,500.00, but the average being $50.00-$100.00) (See Table 12). In regard to the person who delivers the reinforcer, 13 participants reported the judge; two participants reported the case coordinator; one participant reported any team member, and one participant reported the probation officer. Two participants reported that tokens/coupons/vouchers are given during drawings, in court (See Table 13). In regard to how long drug court programs have been providing tokens/coupons/vouchers as positive reinforcement, one participant reported less than 1 year; five participants reported 1-5 years; two participants POSITIVE REINFORCEMENT IN DRUG COURTS 47 reported 6-10 years; two participants reported 11-15 years; four participants reported 16-

20 years, and one response could not be determined/categorized (See Table 14).

Perceived importance of reinforcer. To assess the perceived importance of the reinforcer to drug court clients, participants that endorsed using tokens/coupons/vouchers were asked (via a 5-point Likert-type scale ranging from “Unimportant” to “Very

Important”) how important they thought that this type of reinforcer is to clients’ success.

Fifteen participants reported that they thought it either important (n = 8) or very important (n = 7) (See Table 15). To assess how open drug courts would be to the use of tokens/coupons/vouchers as positive reinforcers, participants reporting that their courts did not use this type of reinforcer were asked, “To the best of your knowledge, how open do you think your court would be to the use of tokens/coupons/vouchers in your program?” This question was asked via a 5-point Likert-type scale ranging from, “Not at

All Open” to “Very Open.” Seven participants responded with “very open”; eight participants responded with “somewhat open”; two participants responded with “neither for nor against”, and two participants responded with “somewhat not open” (See Table

16).

Gift cards/gift certificates. The second type of reinforcer that the survey asked about was gift cards/gift certificates. Of 37 participants who endorsed using positive reinforcement, 31 reported using gift cards as reinforcers/rewards in their drug court programs (See Table 17). These drug court coordinators were asked when (at what time(s) during the program) can a client earn a gift card. Eleven participants reported that clients can earn a gift card at any time in their programs. Three participants reported that clients can earn a gift card in the first phase of their programs, but after an initial period POSITIVE REINFORCEMENT IN DRUG COURTS 48 of 30-60 days. Two participants reported that clients can earn this type of reinforcer weekly; three participants responded with, monthly; three participants responded with, at graduation; one participant responded with, at phase two; five participants responded with, at phase promotions, and 11 participants responded with, after achieving a milestone (e.g., obtaining driver’s license, earning GED or high school diploma, sobriety milestones, obtaining a job, earning a GPA above 2.5). Three responses could not be determined/categorized (See Table 18).

Reinforced behaviors. Drug court coordinators were also asked to identify those behaviors for which clients in their courts can earn a gift card/gift certificate. Twenty- four participants reported that clients in their courts can earn this type of reinforcer for compliance with the program (e.g., attending all groups, attending all urine analyses, meeting the terms of their case plan for the phase of the program that they are in, completing program requirements, making required payments, following through with referrals, attending treatment/counseling and meetings). Five participants reported that clients can earn this type of reinforcer for not having any infractions; three participants responded with, for continued abstinence, and one participant responded with, for attending appointments. Seven participants reported that clients can earn this type of reinforcer for prosocial behaviors (e.g., having a positive attitude, helping a peer, completing community service). Six participants reported that clients can earn this type of reinforcer for phase advancements; two participants responded with, for graduating from the program, and 10 participants responded with, for achieving milestones (e.g., getting their license back, obtaining employment, earning a GPA higher than 2.5, POSITIVE REINFORCEMENT IN DRUG COURTS 49 obtaining clean and sober housing). Nine responses could not be determined/categorized

(See Table 19).

Reinforcer value, delivery, and history. Next, participants were asked what gift cards can be exchanged for. Of the 31 participants who reported that their courts used gift cards/gift certificate, 21 participants reported that gift cards can be exchanged for various store items (e.g., items at Walmart or Target, convenience store items, groceries, clothing, hygiene products, anything except alcohol). Seven participants reported that this type of reinforcer could be exchanged for entertainment (e.g., movies, movie tickets).

Seven participants reported that gift cards could be exchanged for gas; 26 participants responded food (e.g., meals, fast food meals – McDonald’s, Subway, Dunkin Donuts, candy, coffee, groceries, milkshakes), and three participants responded that gift cards could be exchanged for money/cash. It was unclear if they meant that gift cards could be exchanged directly for cash or if they meant that gift cards can function as cash at stores.

Six participants responded that this type of reinforcer could be exchanged for reductions in program responsibilities (e.g., attend fewer meetings/therapy sessions, community service credit, excused from class, a court pass, extended curfew, early dismissal from court). Three responses could not be determined/categorized (See Table 20).

Participants were also asked about the monetary value of gift cards; about who delivers the actual reinforcer, and for the length of time that their programs have been providing this type of reinforcer. Six participants reported a value up to $5.00; 15 participants reported a value up to $10.00; 15 participants reported a value up to $25.00, and one participant reported a value up to $50.00. Three participants reported a value greater than $50.00 (e.g., $100.00 at graduation, up to $250.00, $25.00 - $100.00) (See POSITIVE REINFORCEMENT IN DRUG COURTS 50

Table 21). In regard to the person who delivers the reinforcer, 24 participants reported that was the judge; 10 participants reported, the case coordinator; two participants reported, the case manager, and one participant reported, the probation officer. Two participants reported that gift cards are given during drawings, in court (See Table 22). In regard to how long drug court programs have been providing gift cards as positive reinforcers, two participants reported less than 1 year; 12 participants reported 1-5 years; three participants reported 6-10 years; seven participants reported 11-15 years; five participants reported 16-20 years, and two responses could not be determined/categorized

(See Table 23).

Perceived importance of reinforcer. To assess the perceived importance of the reinforcer to drug court clients, participants that endorsed using gift cards were asked (via a 5-point Likert-type scale ranging from “Unimportant” to “Very Important”) how important they thought that this type of reinforcer is to clients’ success. Twenty-eight participants reported that they thought it either very important (n = 13) or important (n =

15). One participant reported moderately important, and two participants reported of little importance (See Table 24). To assess how open drug courts would be to the use of gift cards as positive reinforcers, participants reporting that their courts did not use this type of reinforcer were asked, “To the best of your knowledge, how open do you think your court would be to the use of gift cards in your program”? This question was asked via a

5-point Likert-type scale ranging from, “Not at All Open” to “Very Open”. One participant responded with, “very open” and one participant responded with “somewhat open” (See Table 25). POSITIVE REINFORCEMENT IN DRUG COURTS 51

Food. The third type of reinforcer the survey asked about was food. Of 37 participants who endorsed using positive reinforcement, 15 reported using food as reinforcers/rewards in their drug court program (Table 26). These drug court coordinators were asked about what types of food and when (at what time(s) during the program) can a client earn food as a reinforcer. Of the 15 participants who reported using food as a reinforcer, 11 participants reported that clients can earn candy (e.g., candy bar, chocolate candy bars, gum, Smarties, Payday candy bars). Eight participants reported that clients can earn baked goods (e.g., cupcakes, cake, cookies, doughnuts, fortune cookies). One participant reported that it was fruit; two participants reported coffee; five participants reported meals (e.g., frito pies, sandwiches, cook out foods, pizza), and four participants reported snack foods (e.g., granola bars, popcorn). One response could not be determined/categorized (See Table 27). In regard to at the times at which the reinforcer could be earned, four participants reported that clients can earn food as a reinforcer at any time in their program. One participant reported that clients can earn food in the first phase of their program, but after an initial period of 30-60 days; one participant responded with, after 120 day; three participants responded with, weekly; one participant responded with, monthly; four participants responded with, at graduation, and one participant responded with, at every court session. One response could not be determined/categorized (See

Table 28).

Reinforced behaviors. Drug court coordinators were also asked about those behaviors for which clients in their courts can earn food. Thirteen participants reported that clients can earn this type of reinforcer for compliance with the program (e.g., being in compliance for a long period, meeting all requirements for the week, returning signed POSITIVE REINFORCEMENT IN DRUG COURTS 52 sober support meeting sheets, weekly compliance, following the program, completing a group goal, meeting the minimum expectations, phase specific behaviors, 100% compliance). One participant reported that clients can earn this type of reinforcer for not having any infractions; one participant responded with, for continued abstinence, and one participant responded with, for perfect compliance for the entire court. Four participants responded with, for graduating from the program, and three participants responded with, for achieving milestones (e.g., school/education goals, employment goals, any milestone). Two responses could not be determined/categorized (See Table 29).

Reinforcer value, delivery, and history. Participants were also asked about the monetary value of the food, about who delivers the actual reinforcer, and for the length of time that their programs have been providing this type of reinforcer. Nine participants reported a value up to $5.00; two participants reported a value up to $25.00, and two participants reported a value up to $50.00. Two responses could not be determined/categorized (See Table 30). In regard to the person who delivers the reinforcer, six participants reported that was the judge; three participants reported, the case coordinator; one participant reported, the case manager; two participants reported, the treatment provider, and one participant reported, the meeting facilitator. Two participants reported that gift cards are given during drawings in court, and two responses could not be determined/categorized (Table 31). In regard to the length of time that drug court programs have been providing food as positive reinforcers, two participants reported less than 1 year; six participants reported 1-5 years; three participants reported

6-10 years; one participant reported 11-15 years; two participants reported 16-20 years, and one response could not be determined/categorized (Table 32). POSITIVE REINFORCEMENT IN DRUG COURTS 53

Perceived importance of reinforcer. To assess the perceived importance of the reinforcer to drug court clients, participants that endorsed using food as reinforcers were asked (via a 5-point Likert-type scale ranging from “Unimportant” to “Very Important”), how important they thought that this type of reinforcer is to clients’ success. Nine participants reported that they thought it is either very important (n = 7) or important (n =

2). Three participants reported moderately important; two participants reported of little importance, and one participant reported unimportant (See Table 33). To assess how open drug courts would be to the use of food as positive reinforcers, participants reporting that their courts did not use this type of reinforcer were asked, “To the best of your knowledge, how open do you think your court would be to the use of food in your program?” This question was asked via a 5-point Likert-type scale ranging from “Not at

All Open” to “Very Open”. Two participants responded with, very open; three participants responded with, somewhat open; six participants responded with, neither for nor against, and two participants responded with, not at all open (See Table 34).

Tangible items. The fourth type of reinforcer the survey asked about was tangible items (e.g., hats, apparel, flowers, bus/train fare). Of 37 participants who endorsed using positive reinforcement, 23 reported using tangible items as reinforcers/rewards in their drug court programs (See Table 35). These drug court coordinators were asked about the types of tangible items can a client earn and when (at what time(s) during the program) a client could earn tangible items as a reinforcer. Of the 23 participants who reported using tangible items as reinforcers, seven participants reported that clients can earn transportation items (e.g., bus pass, gas). Twelve participants reported that clients can earn clothing (e.g., t-shirts, hats, gloves). Nine participants reported accessories (e.g., POSITIVE REINFORCEMENT IN DRUG COURTS 54 lanyards, backpacks, calendars, keychains, bracelets, handbags, jewelry, medallion); three participants reported sports paraphernalia (e.g., Chief’s flag, fishing supplies, sports balls); four participants reported stationary (e.g., adult coloring books, journals, encouragement cards, birthday cards); four participants reported hygiene products (e.g., miscellaneous personal hygiene products, hygiene kits, diapers for their kids); six participants reported household items (e.g., candles, water bottles, small tools, flashlights); six participants reported sobriety items (sobriety token, coin, coins or stones with recovery-oriented words, drug court bracelets); two participants reported candy

(e.g., candy, gum), and six participants reported entertainment items (e.g., DVDs, theater passes, coupons for theme park discounts, movie passes, books, recovery-inspired books). Four responses could not be determined/categorized (See Table 36).

In regard to the time when a client can earn tangible items as a reinforcer, eight participants reported that clients can earn tangible items at any time in their programs.

One participant reported that clients can earn tangible items during holidays (e.g.,

Christmas); one participant responded with, after 90 days; one participant responded with, bi-weekly; two participants responded with, monthly; three participants responded with, at graduation; two participants responded with, after achieving a milestone (e.g.,

GED obtained, milestone achievements), three participants responded with, at phase promotions, and five participants responded that tangible items can be need based (e.g., if they need transportation assistance, any day there is a need). Two participants reported that tangible items are given randomly or during drawings in court. Three responses could not be determined/categorized (See Table 37). POSITIVE REINFORCEMENT IN DRUG COURTS 55

Reinforced behaviors. Drug court coordinators were also asked about those behaviors for which clients in their courts can earn tangible items as a reinforcer. Twelve participants reported that clients can earn this type of reinforcer for compliance with the program (e.g., attending all groups, meeting the terms of their case plan for the phase of the program that they are in, completing program requirements, and attending treatment/counseling and meetings). One participant reported that clients can earn this type of reinforcer for not having any infractions; four participants responded with, for continued abstinence, and one participant responded with, for attending appointments.

One participant reported that clients can earn this type of reinforcer for prosocial behaviors (e.g., positive attitude demonstrations); two participants reported, for phase advancements, two participants responded with, for graduating from the program, and 5 participants responded with, for achieving milestones (e.g., Birthday, milestone achievements, grades). Six participants responded that tangible items can be earned/given if there is a need, and 10 responses could not be determined/categorized (See Table 38).

Reinforcer value, delivery, and history. Participants were also asked about the monetary value of tangible items; about who delivers the actual reinforcer, and for the length of times that their programs have been providing this type of reinforcer. Six participants reported a value up to $5.00; six participants reported a value up to $10.0; six participants reported a value up to $25.00, and two participants reported a value up to

$50.00. Two participants reported a value greater than $50.00 (e.g., up to $100.00, $5.00

- $75.00). Four responses could not be determined/categorized (See Table 39). In regard to the individual who delivers the reinforcer, 13 participants reported that it is the judge; eight participants reported, the case coordinator; four participants reported, the case POSITIVE REINFORCEMENT IN DRUG COURTS 56 manager; two participants reported, any team member; two participants reported, the probation officer, and two participants reported, “other” (e.g., peer support specialists, case aides). Three responses could not be determined/categorized (See Table 40). In regard to the length of time that drug court programs have been providing tangible items as positive reinforcers, two participants reported less than 1 year; eight participants reported 1-5 years; four participants reported 6-10 years; three participants reported 11-

15 years; four participants reported 16-20 years, and one response could not be determined/categorized (See Table 41).

Perceived importance of reinforcer. To assess the perceived importance of the reinforcer to drug court clients, participants that endorsed using tangible items were asked (via a 5-point Likert-type scale ranging from “Unimportant” to “Very Important”) how important they thought that this type of reinforcer is to clients’ success. Twenty participants reported that they thought it either very important (n = 9) or important (n =

11). Two participants reported moderately important, and one participant reported unimportant (See Table 42). To assess how open drug courts would be to the use of tangible items as positive reinforcers, participants reporting that their courts did not use this type of reinforcer were asked, “To the best of your knowledge, how open do you think your court would be to the use of tangible items in your program?” This question was asked via a 5-point Likert-type scale ranging from “Not at All Open” to “Very

Open”. One participant responded with, very open; three participants responded with, somewhat open, and six participants responded with, neither for nor against (See Table

43). POSITIVE REINFORCEMENT IN DRUG COURTS 57

Reductions in program responsibilities. The fifth type of reinforcer the survey asked about was reduction in clients’ program responsibilities. Of 37 participants who endorsed using positive reinforcement, 23 reported using reductions in clients’ program responsibilities in their drug court programs (See Table 44). These drug court coordinators were asked about the types of reductions in program responsibilities a client could earn and when (at what time(s) during the program) a client might earn reductions in program responsibilities as a reinforcer. Of the 23 participants that reported using reductions in program responsibilities as a reinforcer, seven participants reported that clients can earn reduced meetings/check ins (e.g., reduced case coordinator meetings, reduced case management meetings, reduced self-help meetings, fewer check ins with coordinator, less sober support meetings, and fewer phone check-ins). Eight participants reported that clients can earn reduced court sessions (e.g., reduced number of court days per month, skipping an appearance in court, decrease in court hearings). Five participants reported reduced drug screens/drug tests (e.g., reduced number of random urine analyses, reduced drug testing, reduced testing); five participants reported that clients can earn credit for fees (e.g., credit on their fees, reduced program fees, waived fees, skipping a payment fee); one participant reported reduced counseling sessions (e.g., fewer individual and group counseling sessions); one participant reported that clients can earn moving up a phase (e.g., phase up to next phase), and four participants reported extended curfew.

Four participants also reported that clients can earn reduced community service (e.g., less community service hours, community service credit, day off community service); four participants reported that clients can earn a pass to leave court early (e.g., leave court early, reduced time in court, fast pass to leave court after their hearing); one participant POSITIVE REINFORCEMENT IN DRUG COURTS 58 reported that clients can earn fewer requirements over all (e.g., fewer requirements as they phase); one participant reported release from home confinement (e.g., GPS/Home confinement release), and one participant reported reduced sanctions. Five responses could not be determined/categorized (See Table 45).

In regard to the time when a client can earn reductions in program responsibilities as a reinforcer, four participants reported that it could happen at any time in their program

(e.g., entire program, from beginning to end, all phases). Two participants responded with, in first phase, but after an initial period of 30-60 days; one participant responded with, after 180 days; one participant responded with, weekly; five participants responded with, after phase one, and five participants responded with, at phase promotions. Five responses could not be determined/categorized (See Table 46).

Reinforced behaviors. Drug court coordinators were also asked about those behaviors for which clients in their courts can earn reductions in program responsibilities as a reinforcer. Seventeen participants reported that clients can earn this type of reinforcer for compliance with the program (e.g., compliance with individualized case plan, compliant with rules/regulations, in good standing with court and supervision requirements, program compliance, actively engaging in therapy and check ins with coordinator, no unexcused absences, 100 signatures in their calendars, perfect attendance, abiding by curfews). Six participants responded with, for continued abstinence; one participant reported that clients can earn this type of reinforcer for prosocial behaviors

(e.g., positive attitude demonstrations), and two participants reported for phase advancements. Seven responses could not be determined/categorized (See Table 47). POSITIVE REINFORCEMENT IN DRUG COURTS 59

19 participants reported that it is the judge; five participants reported, the case coordinator; two participants reported the case manager; one participant reported, any team member, and one participant reported a treatment provider (See Table 48). In regard to the length of time that drug court programs have been providing reductions in program responsibilities as positive reinforcers, one participant reported less than 1 year; nine participants reported 1-5 years; two participants reported 6-10 years; seven participants reported 11-15 years, and three participants reported 16-20 years (See Table 49).

Perceived importance of the reinforcer. To assess the perceived importance of the reinforcer to drug court clients, participants that endorsed using reductions in program responsibilities were asked (via a 5-point Likert-type scale ranging from “Unimportant” to “Very Important”) how important they thought that this type of reinforcer is to clients’ success. Twenty-one participants reported that they thought it either very important (n =

13) or important (n = 8). One participant reported moderately important (See Table 50).

To assess how open drug courts would be to the use of reductions in program responsibilities as positive reinforcers, participants that reported that their courts did not use this type of reinforcer were asked, “To the best of your knowledge, how open do you think your court would be to the use of tangible items in your program?” This question was asked via a 5-point Likert-type scale, ranging from “Not at All Open” to “Very

Open”. One participant responded with, very open; two participants responded with, somewhat open; two participants responded with, neither for nor against; two participants POSITIVE REINFORCEMENT IN DRUG COURTS 60 said, somewhat not open, and three participants responded with, not at all open (See

Table 51).

Money. The sixth type of reinforcer the survey asked about was money. Of 37 participants who endorsed using positive reinforcement, one reported using money as a reinforcer/reward in his/her drug court program (See Table 52). Drug court coordinators were asked when (at what time(s) during the program) a client could earn money as a reinforcer. The one participant that reported using money as a reinforcer in his/her drug court responded, that clients can earn money at any time in his/her program (See Table

53).

Reinforced behaviors. Drug court coordinators were also about those behaviors for which clients in their courts can earn money as a reinforcer. The one participant that reported using money as a reinforcer responded that clients can earn money for prosocial behaviors (e.g., positive behavior) and during random drawings (e.g. luck of the draw)

(See Table 54).

Reinforcer value, delivery, and history. Participants were also asked about the value of the money, who delivers the actual reinforcer, and for the length of time that their programs have been providing this type of reinforcer. This participant reported a value of $100.00 - $200.00 (e.g., couple of hundred) (See Table 55) and reported that the judge delivers the money (See Table 56). This participant reported that his/her court has been offering money as a positive reinforcer for 6-10 years (e.g., 9 years) (See Table 57).

Perceived importance of the reinforcer. To assess the perceived importance of the reinforcer to drug court clients, participants that endorsed using money were asked POSITIVE REINFORCEMENT IN DRUG COURTS 61

(via a 5-point Likert-type scale ranging from “Unimportant” to “Very Important”) how important they thought that this type of reinforcer is to clients’ success. The only participant to endorse using money as a reinforcer reported that he/she thinks that it is important to clients’ success (See Table 58). To assess how open drug courts would be to the use of tangible items as positive reinforcers, those participants that reported that their courts did not use this type of reinforcer were asked, “To the best of your knowledge, how open do you think your court would be to the use of monetary rewards in your program?” This question was asked via a 5-point Likert-type scale ranging from “Not at

All Open” to “Very Open”. Of the 31 participants reporting that they do not use money as a reinforcer, four participants responded neither for nor against; five participants responded with, somewhat not open, and 22 participants responded with, not at all open

(See Table 59).

Verbal praise. The seventh type of reinforcer the survey asked about was verbal praise. Of 37 participants who endorsed using positive reinforcement, 32 reported using verbal praise as reinforcers/rewards in their drug court programs (See Table 60). These drug court coordinators were asked when (at what time(s) during the program) a client can earn verbal praise as a reinforcer. Seventeen participants reported that clients can earn verbal praise at any time in their programs (e.g., at all phases, entire program, any time, immediately and throughout program, from day one, at entry). One participant reported that clients can earn verbal praise in the first phase, but after an initial period of

30-60 days (e.g., after the first month); one participant responded daily; two participants responded weekly; two participants responded randomly (e.g., randomly during meetings or calls, random); five participants responded with, at court sessions (e.g., attendance in POSITIVE REINFORCEMENT IN DRUG COURTS 62 court sessions, every court session, during drug court docket), and two participants responded with, during case management meetings. Five responses could not be determined/categorized (See Table 61).

Reinforced behaviors. Drug court coordinators were also asked about those behaviors for which clients in their courts can earn verbal praise as a reinforcer. Twenty- seven participants reported that clients can earn this type of reinforcer for compliance with the program (e.g., showing up for meetings, achieving bench marks of case plan, going to treatment, compliance with rules/regulations, Moral Reconation Therapy (MRT) completion, meeting all requirements, doing what judge/team asks of them, maintain all groups, appointments and urine analyses, responsibilities being met, progress in services, working the program, good participation in treatment). Three participants reported that clients can earn this type of reinforcer for not having any infractions; six participants responded with, for continued abstinence, and 16 participants reported that clients can earn this type of reinforcer for prosocial behaviors (e.g., community service, positive attitude demonstrations, positive behavior, going above and beyond what is expected, doing something they were not asked to do, mowing someone’s yard for free). Two participants reported that it could be for phase advancements, and five participants responded with, for achieving milestones (e.g., housing, job, medical, positive life change, voted client of the week or month, getting good grades). Ten responses could not be determined/categorized (See Table 62).

Reinforcer delivery and history. Participants were also asked about the individual who delivers the actual reinforcer and about the length of time that their programs have been providing this type of reinforcer. Twenty-seven participants reported that the judge POSITIVE REINFORCEMENT IN DRUG COURTS 63 delivers the verbal praise; five participants reported, the case coordinator; three participants reported it was the case manager; 15 participants reported, any team member; two participants reported, the probation officer; one participant reported, a treatment provide; one participant reported, law enforcement; five participants reported, legal team members; one participant reported that it was the entire court room, and one participant reported, other clients (See Table 63). In regard to the length of time that drug court programs have been providing verbal praise as a positive reinforcer, one participant reported less than 1 year; seven participants reported 1-5 years; seven participants reported 6-10 years; two participants reported 11-15 years; fourteen participants reported

16-20 years, and one response could not be determined/categorized (See Table 64).

Perceived importance of reinforcer. To assess the perceived importance of the reinforcer in drug court clients, participants that endorsed using verbal praise were asked

(via a 5-point Likert-type scale, ranging from “Unimportant” to “Very Important”) how important they thought that this type of reinforcer is to clients’ success. Thirty-two participants reported that they thought it either very important (n = 26), or important (n =

6) (See Table 65). To assess how open drug courts would be to the use of verbal praise as a positive reinforcer, participants reporting that their courts did not use this type of reinforcer were asked, “To the best of your knowledge, how open do you think your court would be to the use of verbal praise in your program? This question was asked via a 5- point Likert-type scale ranging from “Not at All Open” to “Very Open”. There were no responses because all participants that answered the questions about verbal praise reported currently using verbal praise as a reinforcer in their drug courts (See Table 66). POSITIVE REINFORCEMENT IN DRUG COURTS 64

Certificates of accomplishment. The eighth type of reinforcer the survey asked about was certificates of accomplishment. Of 37 participants who endorsed using positive reinforcement, 25 reported using certificates of accomplishment as reinforcers/rewards in their drug court programs (See Table 67). These drug court coordinators were asked when (at what time(s) during the program) can a client earn certificates of accomplishment as a reinforcer. Two participants reported that clients can earn certificates of accomplishment at any time in their programs. One participant reported that clients can earn a certificate of accomplishment at the start of the program; one participant responded with, after 90 days; 14 participants responded with, at graduation; six participants responded with, after achieving a milestone (e.g., GED obtained, milestone achievements for program phases, graduation of treatment levels – residential, intensive outpatient, outpatient, when they complete MRT, milestone sobriety dates); 15 participants responded with, at phase promotions, and one participant responded with, every court session. One response could not be determined/categorized (See Table 68).

Reinforced behaviors. Drug court coordinators were also asked about those behaviors for which clients in their courts can earn a certificate of accomplishment as a reinforcer. Of the 25 participants that reported using certificates of accomplishment as reinforcers, 10 participants reported that clients can earn this type of reinforcer for compliance with the program (e.g., compliance with rules/regulations, program compliance, completion of phase requirements, completing terms and conditions of treatment plan, achieving phase and program goals). One participant reported that clients can earn this type of reinforcer for not having any infractions; four participants responded with, for continued abstinence; two participants reported that clients can earn this type of POSITIVE REINFORCEMENT IN DRUG COURTS 65 reinforcer for prosocial behaviors (e.g., mowing someone’s yard for free, voted client of the week or month); 11 participants reported, for phase advancements; two participants responded with, for graduating from the program, and one participant responded with, for achieving milestones (e.g., being presented with the Miracle Award). Eleven participants responded with, clients can earn certificates of accomplishment for graduating the entire program (See Table 69).

Reinforcer delivery and history. Participants were also asked about the individual who delivers the actual reinforce, and about the length of time that their programs have been providing this type of reinforcer. In regard to the individual who delivers the reinforcer, of the 25 participants who reported using certificates of accomplishment, 22 participants reported that it is the judge; four participants reported the case coordinator; two participants reported, a treatment provider, and one participant reported, a legal team member (See Table 70). In regard to the length of time that drug court programs have been providing certificates of accomplishment as positive reinforcers, seven participants reported 1-5 years; two participants reported 6-10 years; eight participants reported 11-15 years; seven participants reported 16-20 years, and one response could not be determined/categorized (See Table 71).

Perceived importance of the reinforcer. To assess the perceived importance of the reinforcer in drug court clients, participants that endorsed using certificates of accomplishment were asked (via a 5-point Likert-type scale ranging from “Unimportant” to “Very Important”) how important they thought that this type of reinforcer is to clients’ success. Twenty-four participants reported that they thought it either very important (n =

16) or important (n = 8). One participant reported moderately important (See Table 72). POSITIVE REINFORCEMENT IN DRUG COURTS 66

To assess how open drug courts would be to the use of certificates of accomplishment as positive reinforcers, participants reporting that their courts did not use this type of reinforcer were asked, “To the best of your knowledge, how open do you think your court would be to the use of tangible items in your program?” This question was asked via a 5- point Likert-type scale, ranging from “Not at All Open” to “Very Open”. Four participants responded with, very open; one participant responded with, somewhat open, and two participants responded with, neither for nor against (See Table 73).

“Other” reinforcers. Last, the survey assessed whether or not participants’ drug courts have ever offered or currently offer any “other” type of reinforcer/rewards. As seen in Table 74, five participants reported that their drug courts offered another type of reinforcer. Participants were asked to identify the reward/reinforcer. One participant reported that they sing happy birthday to people. In regard to when (at what time(s) during the program) can a client earn this reinforcer, the participant reported that it occurred when the client celebrated a clean and sober birthday or recovery year. Clients earn this reinforcer if they stay clean on their birthday and/or have made it through a year since their last use of substances. This participant reported that this reinforcer is delivered by everyone in the court room, and they have been offering this reward/reinforcer for 20 years. This participant reported that they think this reinforcer is very important to clients’ success. Another participant reported that his/her drug court offers time spent with the judge or team members as a reward/reinforcer. This participant reported that clients can earn this reinforcer in phase three or four of the drug court program. Clients can earn time spent with the judge or other team members by completing “path 3” for meeting all of their goals. This participant reported that this reinforcer can be exchanged for a special POSITIVE REINFORCEMENT IN DRUG COURTS 67 dinner with a team member of the client’s choice; this is worth a monetary value of

$60.00. The reinforcer is delivered by the judge, and this participant’s court has been providing this reinforcer for three years. This participant reported that they think this reward is very important to clients’ success (See Table 74).

Another participant reported that his/her drug court offers paying for other community referrals (parenting classes, domestic violence treatment that’s not covered by insurance, etc.) as a reinforcer/reward. This participant reported that this reward is offered daily for being in compliance, and the monetary value of this reward varies. This participant reported that this reward is offered by the Mentor Coordinator and Program

Coordinator, and they have been offering this as a reward for five years. This participant reported that they think this reward is very important to clients’ success. Another participant reported that his/her drug court offers clients that have completed their drug court program with the opportunity to earn part or all of the money back that they paid for the program. This reward is offered after graduation, and a client must remain drug free, keep a job, and have no new charges in order to earn this reward. This participant reported that the monetary value of this reward is approximately $3,000.00, and the reward is delivered by the judge. This participant reported that this reward has been offered for 9 years, and he/she thinks it is important to clients’ success (See Table 74).

The last “other” type of reinforcer that a participant endorsed using was a standing ovation, which can be earned weekly, in court. This participant reported that a client must be the “best of the week” to earn a standing ovation, which is delivered by the judge and treatment staff. This participant reported that his/her court has been offering POSITIVE REINFORCEMENT IN DRUG COURTS 68 this reward for five years, and he/she thinks it is important to clients’ success (See Table

74).

Perceived openness to “other” reinforcers. To assess how open drug courts would be to the use of other types of reinforcers/rewards, participants reporting that their courts did not use any “other” types of reinforcers/rewards were asked, “To the best of your knowledge, how open do you think your court would be to the use of other types of reinforcers in your program?” This question was asked via a 5-point Likert-type scale ranging from “Not at All Open” to “Very Open”. Six participants responded very open; nine participants responded with, somewhat open, and three participants responded with, neither for nor against (See Table 74).

Drug Court Programs Additional Information

Finally, participants were asked what initiated or caused them to implement reinforcers/rewards into their programs and how their reinforcers/rewards are funded.

Reason for implementation of positive reinforcement. In regard to what initiated or caused drug courts to start implementing positive reinforcement, three participants reported that research on the effectiveness of positive reinforcement caused them to start using rewards/reinforcers (e.g., the research and data behind positive reinforcers research showed it to be effective, we know people react better to praise and rewards as opposed to negative behaviors). Thirteen participants responded best practices

(e.g., best practices dictate the use of rewards, part of best practices, best practice standards, we always look at best practice and look for innovative ideas from other courts regarding incentives when attending conventions or conferences, NADCP best practices). POSITIVE REINFORCEMENT IN DRUG COURTS 69

Six participants responded with, to motivate/encourage clients (motivational interviewing and desire for positive reinforcement in lieu of negative reinforcement; rewards for positive behavior reinforces the behavior; encouragement for client success; to motivate behavioral changes; praise and acknowledgement of progress is critical to behavior change and motivation; to entice clients to remain drug free). Three participants responded with, training (e.g., training and just improving over the years for what we found to work with kids, through training, our training). Seven participants responded with, unknown (See Table 75).

Funding of positive reinforcers. In regard to funding, 11 participants responded that reinforcers/rewards funding is part of their budget/program funding (e.g., operating budget, budgeted in our funds, funds set aside, county funds, superior court budget line item, judge’s budget, program funding, appropriations from the General Fund and supplemental state funding). Five participants responded with, through grants (e.g., grant funds, state grant funding, grant funds – state and federal). Fourteen participants responded with, through donations (e.g., donations, donated items, solicited from the community, Friends of New Hampshire DTC, some businesses donate). One participant responded with, through fundraising; eight participants responded with, through client fees (e.g., participant fees, fees participants pay as requirement to graduate drug court, program fees, drug court fees, defendants phase up fees); two participants reported, through sales tax (e.g., local sales tax funding, mental health sales tax in our county), and two participants reported that their reinforcers/rewards are free (See Table 76).

POSITIVE REINFORCEMENT IN DRUG COURTS 70

Discussion

Implications

Operant Conditioning, which postulates that behavior is influenced by the consequences that follow the behavior (e.g. reinforcement and punishment), may be as close to a law, as one might exist in psychology. Contingency Management (CM), an

Operant Conditioning technique, has been found to be one of the most effective methods for changing behaviors, especially substance use (add refs Chambless & Ollendick,

2001). Specifically, CM is an evidence-based practice that has been shown to be highly effective in treating substance use disorders (e.g. Budney, Higgins, Radonovich, & Novy,

2000; Roll, Higgins, & Badger, 1996; Petry, Martin, Cooney, & Kranzler, 2000; Bickel,

Amass, Higgins, Badger, & Esch, 1997; Stitzer, Iguchi, & Felch, 1992; Silverman et al.,

1996). However, regardless of overwhelming empirical support of its efficacy, many substance abuse programs fail to use CM in routine practice (Kirby, Benishek, Dugosh, &

Kerwin, 2006).

This study allowed the researcher to determine (1) the proportion of drug courts that use positive reinforcement, (2) how drug courts perceive the use of reinforcement, and (3) how drug courts that use positive reinforcment implement the strategy. This information is beneficial because it offers providers and policy makers information that may be helpful in addressing potential barriers to the use of positive reinforcement in drug courts. Additionally, specific information about those forms of positive reinforcement that drug courts use and how these are implemented, may be beneficial because it allows researchers to advise drug courts about those forms of positive POSITIVE REINFORCEMENT IN DRUG COURTS 71 reinforcement that are perceived as most effective and how these can best be implemented.

Research has shown that the efficacy of drug courts is largely attributed to adherence to strict principles of behavioral modification (Festinger et al., 2002), and the perceived deterrence theory. This theory states that the likelihood that an offender will engage in drug use or illegal activity is influenced by the perceived certainty of being detected for infractions or recognized for accomplishments, the perceived certainty of receiving sanctions/punishments for infractions or rewards for accomplishments, and the anticipated strength of those punishments and rewards (Marlowe, Festinger, Foltz, Lee, &

Patapis, 2005). The drug court model is a behavioral model that provides clear expectations and graduated sanctions and rewards for infractions and accomplishments.

Drug courts heavily utilize the threat of punishment aspect of behavioral interventions, via graduated sanctions, if participants do not adhere to the rules and expectations; however, past research shows that they do not often use positive or negative reinforcement for appropriate behaviors (Marlowe & Wong, 2008). Despite its popularity, negative reinforcement may be less beneficial because it often involves reductions in participants’ treatment or supervisory obligations (treatment sessions, urinalysis, court appearances), which are critical to the effectiveness of the program.

Positive reinforcement has been shown to be more effective in initiating and maintaining long term behavior change than punishment/sanctions (Martin & Pear, 2014).

Unfortunately, sanctions are usually more readily available than rewards within drug courts (Marlowe & Wong, 2008). The purpose of this study was to survey drug courts, POSITIVE REINFORCEMENT IN DRUG COURTS 72 across the country, about their use, perceptions, and practices of positive reinforcement strategies.

Comparisons of Reinforcers

Most and least popular types of reinforcers. Results from this study showed that the majority of drug court coordinators that were sampled use positive reinforcement.

This finding was unexpected, given the fact that previous research suggested that positive reinforcement was not often used in drug courts (Marlowe & Wong, 2008). Drug court coordinators endorsed using nine different types of reinforcers in their drug court programs. As shown in the results, the most prevalent reinforcer used was verbal praise.

Eighty-six percent of participants reported using this type of reinforcer. The second most frequently used reinforcer was gift cards. Eighty-four percent of participants reported using this type of reinforcer. The third most frequently used reinforcer was certificates of accomplishment. Sixty-seven percent of participants reported using this type of reinforcer. The fourth most frequently used reinforcers were tangible items and reductions in program responsibilities. Both were endorsed by 62% of participants. The fifth most frequently used reinforcer was tokens/coupons/vouchers. Fifty-four percent of participants reported using this type of reinforcer. The sixth most frequently used was food (41% of participants), and the seventh most frequently used was “other” types of reinforcers (14%). The least frequently used reinforcer was money. Only one participant reported that his/her drug court used money as a reinforcer. These findings are interesting because previous research has indicated that reductions in program responsibilities

(negative reinforcement) is used more often than positive reinforcement (Marlowe &

Wong, 2008). It appears that in the past 10 years, drug courts have increased their use of POSITIVE REINFORCEMENT IN DRUG COURTS 73 reinforcement and have explored using other types of positive reinforcement that had not been used before.

In regard to gift cards, the majority of participants reporting the use of gift cards as positive reinforcers, stated that they were for food. Common responses included fast food restaurants, such as McDonald’s, Subway, and Dunkin Donuts. The second most common type of gift card given as a positive reinforcer was used for various stores/various store items. Common responses were stores such as Walmart and Target.

The third most common types of gift cards were entertainment gift cards (used for movie tickets) and gas. The least frequently used type of gift card was gift cards that could be exchanged for money/cash. It was unclear if participants meant that gift cards could be exchanged directly for cash or if they meant that gift cards can function as cash at stores.

In regard to food, the majority of participants that reported using food as a positive reinforcer stated that candy was the most frequently earned food item. Common responses included candy bars, gum, Smarties. The second most common type of food given as a positive reinforcer was baked goods. Common responses were cupcakes, cake, cookies, and doughnuts. The third most common type of food was a meal. Common responses included Frito pies, pizza, and sandwiches. The least frequently used type of food was fruit.

In regard to tangible items, clothing was the most frequently used tangible item.

Common responses included t-shirts, hats and gloves. The second most common type of tangible items given as positive reinforcers were accessories. Common responses were lanyards, key chains, and bracelets. The third most common types of tangible items given as positive reinforcers were transportation items. Common responses were bus passes and POSITIVE REINFORCEMENT IN DRUG COURTS 74 gas. The least frequently used type of tangible item was candy, but this is likely because most participants classified candy as a food and listed it in the questions about food reinforcers.

In regard to reductions in program responsibilities, reduced number of court sessions was the most frequently used reduction. Common responses included reduced number of court days per month, skipping an appearance in court, decrease in court hearings. The second most common type of reduction in program responsibilities given as a positive reinforcer was reduced meetings/check ins. Common responses were reduced case coordinator meetings, reduced case management meetings, reduced self- help meetings, fewer check ins with coordinator, less sober support meetings. The third most common types of reductions given as positive reinforcers were credit for fees (credit on their fees, reduced program fees, waived fees, skipping a payment fee) and reduced drug screens/drug tests (reduced number of random urine analyses, reduced drug testing, reduced testing). The least frequently used types of reductions in program responsibilities were reduced counseling sessions (fewer individual and group counseling sessions), moving up a phase (phase up to next phase), fewer requirements over all (fewer requirements as they phase), release from home confinement (GPS/Home confinement release), and reduced sanctions. One participant reported using each one of these types of reductions.

Timing of reinforcer delivery. Drug court coordinators were also asked about times when clients could earn these reinforcers. Although timing varied for the different types of reinforcers, as indicated in the results, the most frequently reported time when clients could earn the majority of reinforcers (tokens/coupons/vouchers, gift cards, food, POSITIVE REINFORCEMENT IN DRUG COURTS 75 tangible items, and verbal praise) was any time. The second most frequent response for times when clients can earn reinforcers was at phase promotions. Overall, the least frequent responses were any time after 90 days, daily, any time after 180 days, holidays, during the second phase, after 90 days, at the start of the program, and after 120 days.

Interestingly, the least frequent responses for times when a client can earn verbal praise were daily and after an initial period of 30-60 days. One participant endorsed the idea that clients can earn verbal praise at each of those times. This was one of the most surprising results for this question because verbal praise does not cost any money and is fairly easy to use. It is unfortunate that only one participant reported that verbal praise can be earned daily, if appropriate. It is unfortunate, especially, when every participant that reported using verbal praise thought it is either very important or important to clients’ success.

Very few courts provided a prize only at the end of the treatment program/at graduation.

This may not technically meet the definition of a reinforcer, if drug court clients had not been exposed to it throughout the program, so that treatment team members could observe how the reinforcer affects clients’ behavior. However, most courts endorsed providing reinforcers along the way, in addition to providing a prize at the end of the treatment program.

Comparisons of how clients earn different reinforcers. Drug court coordinators were also asked about those behaviors that clients can use to earn these reinforcers. The most frequent response across all reinforcers was compliance. The second most frequent response across all reinforcers was for prosocial behaviors. The least frequent response across all reinforcers was perfect compliance for the entire court. More specifically, compliance with the drug court program was the most frequent response for POSITIVE REINFORCEMENT IN DRUG COURTS 76 tokens/coupons/vouchers, gift cards, food, tangible items, program reductions, and verbal praise. The most frequent responses for certificates of accomplishment were for phase advancements and graduating from the program. Overall, besides compliance, the next most frequent responses for ways in which clients earn reinforcers were achieving milestones and graduating from the program. The least frequent responses for ways in which a client can earn a token/coupon/voucher were attending appointments and phase advancements. The least frequent response for gift cards was also attending appointments. The least frequent responses for ways in which clients can earn food were not having infractions, perfect compliance for the entire court, and continued abstinence.

The least frequent responses for ways in which clients earn tangible items were not having infractions, attending appointments, and prosocial behaviors. The least frequent response for reductions in program responsibilities was prosocial behaviors. The least frequent response for verbal praise was phase advancements. The least frequent responses for ways in which clients earn certificates of accomplishment were achieving a milestone and not having infractions. It is surprising that not having infractions and continued abstinence were among some of the least frequent responses for ways to earn reinforcers.

However, this may be that participants considered compliance to include not having infractions and continued abstinence. If so, they may not have specified avoiding infractions completely and continued abstinence as ways to earn specific reinforcers.

Additionally, a behavior that courts may want to consider reinforcing more emphatically is attending appointments because that behavior seems to be infrequently reinforced by the majority of drug courts sampled. POSITIVE REINFORCEMENT IN DRUG COURTS 77

Comparisons of who delivers different reinforcers. Drug court coordinators were also asked about is the individual who delivers the actual reinforcers to drug court clients. This question was particularly important due to research that exists on the effectiveness of having the judge deliver the reinforcers. Considerable attention has been given to the symbolic impact of the “black robe”. It is thought that the “black robe” makes the role of the judge in status hearings central to the efficacy of drug courts (Satel,

1998). Defendants often credit at least part of their success in drug courts to the fact that a powerful individual, like a judge, took a personal interest in them (Goldkamp, White, &

Robinson, 2002). It appears that drug courts are aware of this research because the most frequent response for the person who delivers the reinforcers, for all 9 reinforcers, was the judge. The second most frequent response was the drug court coordinator. Least frequent responses included legal team, entire court room, meeting facilitator, other participants, and law enforcement.

Comparisons of values of different reinforcers. Drug court coordinators were also asked about the value/expense of these reinforcers. The most frequent response across all reinforcers was up to $25.00, and the second most frequent response was up to

$10.00. The least frequent response across all reinforcers was, no value. The most expensive reinforcer reported was money. One participant reported that clients can earn

$100-$200. Reinforcers that had no associated monetary cost were reductions in program responsibilities, verbal praise, and certificates of accomplishment.

Comparisons of how long different reinforces have been provided.

Additionally, drug court coordinators were asked how long they have been providing these types of reinforcers to drug court clients. The most frequent response across all POSITIVE REINFORCEMENT IN DRUG COURTS 78 reinforcers was 1-5 years. The second most frequent response was 16-20 years. The least frequent response was 6-10 years. Not surprisingly, verbal praise was endorsed most frequently as being the reinforcer provided for the longest period of time (16-20 years).

This is likely because it is the cheapest and easiest reinforcer to give. The second cheapest and easiest to deliver reinforcer was certificates of accomplishment, and these have been provided for the second longest period of time. The other six reinforcers, which cost more, have been provided only for fewer than or equal to 10 years.

Comparisons of importance of different reinforcers. In regard to importance of the reinforcer, the most frequent response, regardless of the individual types of reinforcers, was that it was deemed very important. The second most frequent response was that it was considered important, and the least frequent response was that it was unimportant. More specifically, the reinforcers that were most frequently considered very important were food, tangible items, reductions in program responsibilities, verbal praise, and certificates of accomplishment. The reinforcers that a few participants reported as unimportant were food and tangible items. These results are important because they show that, overall, the majority of participants thought that all types of reinforcers are either very important or are important to drug court clients’ success.

Comparisons of perceived openness to different reinforcers. Drug court coordinators reporting that they do not use these types of reinforcers were asked how open they think their courts would be to using these reinforcers. The most frequent response, regardless of individual type of reinforcer was, somewhat open. The second most frequent response was, very open. The least frequent response was, somewhat not open. More specifically, the reinforcers most frequently voted very open or somewhat POSITIVE REINFORCEMENT IN DRUG COURTS 79 open were tokens/coupons/vouchers, gift cards, and certificates of accomplishment. The reinforcer most frequently voted as somewhat not open or not at all open was reductions in program responsibilities. This finding contradicts previous research, which suggests that drug courts more often use negative reinforcement instead of positive reinforcement

(Marlowe & Wong, 2008). This suggests that over the past 10 years, drug courts have become more aware of the effectiveness of positive reinforcement and have become less favorable to using negative reinforcement than they previously were.

Review of money. Only one drug court coordinator reported using money as a positive reinforcer in his/her drug court. Therefore, money was not included in the previously noted summaries. Not surprisingly, 31 participants reported that they do not use money as a reinforcer in their drug courts, and of those 31 participants, 22 of them reported that they thought their courts would be not at all open to using money as a positive reinforcer. This is likely because using money as a reinforcer provides very little control over what drug court clients spend the money on. Given the population that drug courts serve, these concerns are understandable. However, the one participant that reported using money at his/her drug court reported that he/she thought it was very important to clients’ success. Interestingly, he/she reported that money can be earned at any time, but most often is earned for prosocial behaviors or through a drawing. This participant reported that clients can earn $100-200, and the money is delivered by the judge. It appears that this drug court finds this reinforcer to be effective because his/her court has been provided money for 6-10 years. It would be interesting in future research to ask the participants that do not use money and do not think their courts would be open POSITIVE REINFORCEMENT IN DRUG COURTS 80 to using money as a reinforcer, about the reasons why they are against using it or why they think that way.

Review of “other” reinforcers. Only five drug court coordinators reported using

“other” types of positive reinforcement in their drug courts. Therefore, “other” reinforcers were also not included in these summaries. The “other” reinforcers that participants reported using were: singing happy birthday, time spent with the judge and treatment team, having the drug court pay for referrals, earning program cost/fees back, and a standing ovation. In regard to these reinforcers, the most frequent response to the question about the person who delivered them was, the judge. These reinforcers have been provided for 3-20 years; singing happy birthday has been used as a reinforcer for 20 years and time spent with the judge and treatment team has been used for 3 years. All 5 participants reported that they thought these reinforcers were either very important or important to clients’ success. Singing happy birthday and standing ovations have no associated costs, so they may be reinforcers that other drug courts may want to consider using.

Limitations

There are several limitations that impacted the internal and external validity of this study. One limitation centers around the inclusion and exclusion criteria. This study sampled only drug court coordinators from pretrial adult drug courts in the United States of America that were identified on the National Association of Drug Court Professionals

(NADCP) website. This study did not sample other drug court employees or drug court clients, and it did not sample drug court coordinators from drug courts outside of the

United States of America. Only pre-trial adult drug courts were included because they POSITIVE REINFORCEMENT IN DRUG COURTS 81 generally represent the most traditional and most prevalent drug courts in the country

(Marlowe, Hardin, & Fox, 2016). Although the sample had seemingly good geographical representation, there are over 3,000 drug courts in the country, today, and this study represented only 13 states. Also, by sampling only pre-trial adult drug court coordinators, the results cannot be expected to generalize to post-sentencing and other types of courts.

A more inclusive sample would increase the generalizability of the study findings.

Another limitation to this study was the survey design. Surveys utilize self-report, which presents potential threats to validity. Specifically, self-report surveys rely on the honesty of participants. This is a potential threat to validity because participants may not be entirely honest with their responses. Additionally, even if participants are trying to be honest, they may lack the knowledge or introspective ability to provide an accurate response to a question. Participants may also vary regarding their understanding or interpretation of particular questions. Questions were worded as specifically as possible to try to avoid this threat to validity, but it is always possible that individual participants will interpret the questions differently. Relatedly, the researcher used Survey Monkey to distribute the survey online, which did not allow the researcher to meet with or directly observe the participants. This raises additional questions about the fidelity of the online survey.

A final limitation to this study was the somewhat limited sample size (N = 39). A larger sample size would provide more information and increase the statistical power.

Survey studies of this type are rarely able to achieve a perfect response rate. Although it is likely that the assistance of NADCP’s Chief of Training and Research greatly improved the response rate, the ultimate sample was much lower than initially planned. POSITIVE REINFORCEMENT IN DRUG COURTS 82

Also, with this study design, there was no way to assess the differences between responders and non-responders, which precludes the identification of possible systematic differences between the two.

Future Research

In the future, if this study were to be replicated, it may be beneficial to have researchers review each court’s written program manuals. It also may be beneficial to have researchers visit the courts to observe if and how positive reinforcement is used.

These strategies may decrease some of the validity issues associated with self-report. It would also be beneficial to expand the study to different types of drug courts to assess if and how other types of courts use positive reinforcement. Assessment of the use of positive reinforcement in other types of drug courts, such as Veteran Treatment Courts,

Family Dependency Treatment Courts, Designated DWI Courts, Tribal Healing to

Wellness Courts, Co-Occurring Disorders Courts, Post-Sentencing Courts, and/or Re- entry Courts is warranted. This would allow researchers to determine not only the degree to which, but also how these alternative drug courts employ positive reinforcement, including how they are perceived. Positive reinforcement is one of the most effective methods for changing behavior. Therefore, if drug courts are not utilizing this method, it would be important for researchers to spread awareness of the benefits and effectiveness of using positive reinforcement to decrease substance use and criminal recidivism.

Incentivizing productive behaviors is a key element that is listed under the NADCP’s adult drug court best practice standards. Incentives and rewards are critical elements of drug courts that must be included so that they may meet the acceptable standards of competencies as set forth by their association (NADCP, 2018). Additionally, if other POSITIVE REINFORCEMENT IN DRUG COURTS 83 types of drug courts are using positive reinforcement, it would be beneficial for future research to assess this and determine what specific reinforcers that other types of drug courts are using, including how they are implementing these, and how effective they are in decreasing substance use and criminal recidivism. This research would be beneficial because it would help ensure that drug courts are using and implementing CM-based procures in the most efficient and effective ways.

It would also be beneficial for future research to look at the reasons why some drug court coordinators do not use these nine types of reinforcers, as well as the reasons why they do not think that their courts would be open to using these types of reinforcers.

It would also be helpful to get more complete representation from the drug court team.

For example, it would be wise to include judges, other drug court employees, and other stakeholders in the sample. This would be particularly important for assessing the issues associated with other types of reinforcers that might be used and the importance and perceived openness to using those reinforcers. Additionally, it would also be interesting to determine drug court clients’ perspectives on the use of positive reinforcement in their drug courts, especially which reinforcers they consider to be the most effective.

Future research could also look at potential interactions/moderator effects. It may be worth exploring those types of reinforcers that work best for different types of client populations. For example, it would be interesting to look at schedules of reinforcement.

Most drug courts use an escalating schedule of reinforcement, as evidenced by these results and previous research (Festinger, Marlowe, Lee, Kirby, Bovasso, & McLellan,

2002), but some client populations may benefit more fully from starting with larger reinforcers to engage clients and then thinning them out over the course of the program. POSITIVE REINFORCEMENT IN DRUG COURTS 84

Previous research supports the fact that clients diagnosed with Antisocial Personality

Disorder may do better with this schedule of reinforcement (Festinger et al., 2002).

Conclusion

Drug courts represent an important area of criminal justice reform. It is understood that substance use and criminal behavior may be influenced by many factors other than morality, alone; this includes biological, genetic, and biopsychosocial factors.

Therefore, this type of research is critical to help improve our public health and our public safety. POSITIVE REINFORCEMENT IN DRUG COURTS 85

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Tables

Table 1.

Participant Demographics

Number of Variable Responses Mean SD Median Min Max Age (Years) 30 47.20 11.07 47.00 28.00 70.00 Length of Employment 31 5.94 5.14 4.67 0.25 18.17 (Years)

Table 2. Do any members of your family have a substance use disorder?

Category Frequency Yes 13 No 14 Prefer not to answer 4

Table 3. What type of criminal offenders participate in your drug court (what type of drug court are you)?

Category Frequency Felony 15 Misdemeanor 3 Both Felony and Misdemeanor 14 Violent Crimes 0 Non-violent Crimes 25 Both Violent and Non-violent Crimes 3 Drugs 25 DUI 12 Hybrid 7 Other 7 SPMI diagnosis 1 Pre-sentencing/Post-sentencing 1 Juveniles 1 No prior charges of drug trafficking or violence 1 Non-drug crimes committed primarily due to drug use 1 Mental health 1 POSITIVE REINFORCEMENT IN DRUG COURTS 96

Table 4.

Drug Court Demographics

Number of Variable Responses Mean SD Median Min Max Avg. No. of Clients 31 44.97 44.13 24.00 1.00 199.00 Current No. of Clients 31 53.65 46.44 38.00 10.00 170.00 Number of Judges 35 1.11 0.32 1.00 1.00 2.00 Length of Program (Years) 30 1.27 0.36 1.21 0.67 2.25 Length of Operation 31 12.35 6.91 12.56 1.00 28.02 (Years)

Table 5. If pharmacological treatments are used in your program, which ones? (Please select all that you use)

Response Frequency No 8 Yes 23 Suboxone 21 Naltrexone 18 Methadone 11 Antabuse/Disulfiram 5 N/A 8 Vivitrol 2

POSITIVE REINFORCEMENT IN DRUG COURTS 97

Table 6. What are the requirements for graduation from your court program?

Category Frequency Complete Treatment 39 Continued abstinence 23 Fines paid 11 No charges 3 Community service 4 Fundraising 1 Lead a group session 1 Complete Self-Sufficiency Goals 23 Relapse prevention/continuing care plan 13 Apology Letter 2 Final Essay/project 5 Cannot be determined 5

Table 7. Do you use positive reinforcement (rewards) in your drug court?

Category Frequency Yes 37 No 2 Blank 45

Table 8. Have you offered or do you currently offer tokens/coupons/vouchers (that can be exchanged for prizes) as reinforcers/rewards?

Category Frequency Yes 20 No 17 Blank 47

POSITIVE REINFORCEMENT IN DRUG COURTS 98

Table 9.

When (at what time(s) during the program) can a client earn a token/coupon/voucher?

Category Frequency Any time 8 In first phase, but after an initial period of 30-60 days 4 Weekly 1 Biweekly 1 Monthly 0 Graduation 1 Cannot be determined 1

Table 10. How does a client earn a token/coupon/voucher (for what behaviors)? Category Frequency Compliance 11 Not having infractions 3 Continued abstinence 3 Attending appointments 2 Prosocial behaviors 5 Phase advancements 2 Achieving milestones 5 Cannot be determined 5

Table 11. What can tokens/coupons/vouchers be exchanged for?

Category Frequency Gift cards 10 Entertainment 6 Food 7 Money 1 Cannot be determined 4

POSITIVE REINFORCEMENT IN DRUG COURTS 99

Table 12. What is the monetary value of the token/coupon/voucher?

Category Frequency No value 1 Up to $5 5 Up to $10 6 Up to $25 5 Up to $50 0 Greater than $50 1

Table 13. Who delivers the token/coupon/voucher?

Category Frequency Judge 13 Case Coordinator 2 Drawing/random 2 Any team member 1 Probation officer 1

Table 14. How many years has your program been providing tokens/coupons/vouchers to clients?

Category Frequency Less than 1 year 1 1-5 years 5 6-10 year 2 11-15 years 2 16-20 years 4 Cannot be determined 1

Table 15.

How important do you think tokens/coupons/vouchers are to clients’ success?

Category Frequency Very Important 7

Important 8 POSITIVE REINFORCEMENT IN DRUG COURTS 100

Table 16. To the best of your knowledge, how open do you think your court would be to the use of tokens/coupons/vouchers in your program?

Category Frequency Very Open 7 Somewhat Open 8 Neither For or Against 2 Somewhat Not Open 2

Table 17. Have you offered or do you currently offer gift cards/certificates as reinforcers/rewards?

Category Frequency Yes 31 No 2 Blank 51

Table 18. When (at what time(s) during the program) can a client earn a gift card/certificate?

Category Frequency Any time 11 In first phase, but after an initial period of 30-60 days 3 Weekly 2 Biweekly 0 Monthly 3 Graduation 3 After achieving a milestone 11 Second phase 1 Phase promotions 5 Cannot be determined 3

POSITIVE REINFORCEMENT IN DRUG COURTS 101

Table 19. How does a client earn a gift card/certificate (for what behaviors)?

Category Frequency Compliance 24 Not having infractions 5 Continued abstinence 3 Attending appointments 1 Prosocial behaviors 7 Phase advancements 6 Graduation 2 Achieving a milestone 10 Cannot be determined 9

Table 20. What can gift cards/certificates be exchanged for?

Category Frequency Various store items 21 Entertainment 7 Gas 7 Food 26 Reduction in program responsibilities 6 Money 3 Cannot be determined 3

Table 21. What is the monetary value of the gift card/certificate?

Category Frequency No Value 0 Up to $5 6 Up to $10 15 Up to $25 15 Up to $50 1 Greater than $50 3 Cannot be determined 1

POSITIVE REINFORCEMENT IN DRUG COURTS 102

Table 22.

Who delivers the gift card/certificate?

Category Frequency Judge 24 Coordinator 10 Case manager 2 Drawing/random 2 Any team member 0 Probation officer 1 Cannot be determined 0

Table 23. How many years has your program been providing gift cards/certificates to clients?

Category Frequency Less than 1 year 2 1-5 years 12 6-10 years 3 11-15 years 7 16-20 years 5 Cannot be determined 2

Table 24. How important do you think gift cards/certificates are to clients’ success?

Category Frequency Very Important 13 Important 15 Moderately Important 1 Of Little Importance 2

Table 25. To the best of your knowledge, how open do you think your court would be to the use of gift cards/certificates in your program?

Category Frequency Very Open 1 Somewhat Open 1 POSITIVE REINFORCEMENT IN DRUG COURTS 103

Table 26. Have you offered or do you currently offer food as reinforcers/rewards?

Category Frequency Yes 15 No 13 Blank 51

Table 27. What type(s) of food?

Category Frequency Candy 11 Baked goods 8 Fruit 1 Coffee 2 Meals 5 Snack foods 4 Cannot be determined 1

Table 28. When (at what time(s) during the program) can a client earn the food?

Category Frequency Any time 4 In first phase, but after an initial period of 30-60 days 1 After 120 days 1 Weekly 3 Biweekly 0 Monthly 1 Randomly 0 Graduation 4 After achieving a milestone 0 Second phase 0 Every court session 1 Phase promotions 0 Cannot be determined 1 POSITIVE REINFORCEMENT IN DRUG COURTS 104

Table 29. How does a client earn the food (for what behaviors)?

Category Frequency Compliance 13 Fishbowl 0 Not having infractions 1 Perfect compliance for entire court 1 Continued abstinence 1 Attending appointments 0 Community Service 0 Helping a peer 0 Positive attitude 0 Phase advancements 0 Achieving a milestone 3 Graduation 4 Cannot be determined 2

Table 30. What is the monetary value of the food?

Category Frequency No value 0 Up to $5 9 Up to $10 0 Up to $25 2 Up to $50 2 Greater than $50 0 Cannot be determined 2

POSITIVE REINFORCEMENT IN DRUG COURTS 105

Table 31. Who delivers the food?

Category Frequency Judge 6 Coordinator 3 Case manager 1 Drawing/random 2 Any team member 0 Probation officer 0 Meeting facilitator 1 Treatment provider 2 Cannot be determined 2

Table 32. How many years has your program been providing food (as a reinforcer) to clients?

Category Frequency Less than 1 year 2 1-5 years 6 6-10 year 3 11-15 years 1 16-20 years 2 Cannot be determined 1

Table 33.

How important do you think food (as a reinforcer) is to clients’ success?

Category Frequency Very Important 7 Important 2 Moderately Important 3 Of Little Importance 2 Unimportant 1 POSITIVE REINFORCEMENT IN DRUG COURTS 106

Table 34. To the best of your knowledge, how open do you think your court would be to the use of food (as a reinforcer) in your program?

Category Frequency Very Open 2 Somewhat Open 3 Neither For or Against 6 Not at all Open 2

Table 35. Have you offered or do you currently offer tangible items (e.g., hats, apparel, flowers, bus/train fare) as reinforcers/rewards?

Category Frequency Yes 23 No 10 Blank 51

Table 36.

What types of items can clients earn?

Category Frequency Transportation items 7 Clothing 12 Accessories 9 Sports paraphernalia 3 Stationary 4 Hygiene products 4 Household items 6 Continued abstinence items 6 Candy 2 Entertainment items 6 Cannot be determined 4 POSITIVE REINFORCEMENT IN DRUG COURTS 107

Table 37. When (at what time(s) during the program) can a client earn these tangible items?

Category Frequency Any time 8 Holidays 1 In first phase, but after an initial period of 30-60 days 0 After 90 days 1 After 120 days 0 Weekly 0 Biweekly 1 Monthly 2 Randomly 2 Graduation 3 After achieving a milestone 2 Second phase 0 Every court session 0 Phase promotions 3 Need based 5 Cannot be determined 3

Table 38.

How does a client earn these tangible items (for what behaviors)?

Category Frequency Compliance 12 Fishbowl 0 Not having infractions 1 Perfect individual compliance 0 Perfect compliance for entire court 0 Continued abstinence 4 Attending appointments 1 Community Service 0 Helping a peer 0 Prosocial behaviors 1 Phase advancements 2 Graduation 2 Achieving a milestone 5 Need based 6 Cannot be determined 10 POSITIVE REINFORCEMENT IN DRUG COURTS 108

Table 39.

What is the monetary value of each of these tangible items?

Category Frequency No value 0 Up to $5 6 Up to $10 6 Up to $25 6 Up to $50 2 Greater than $50 2 Cannot be determined 4

Table 40. Who delivers the tangible items?

Category Frequency Judge 13 Coordinator 8 Case manager 4 Drawing/random 0 Any team member 2 Probation officer 2 Treatment provider 0 Other 2 Cannot be determined 3

Table 41. How many years has your program been providing tangible items to clients?

Category Frequency Less than 1 year 2 1-5 years 8 6-10 year 4 11-15 years 3 16-20 years 4 Cannot be determined 1 POSITIVE REINFORCEMENT IN DRUG COURTS 109

Table 42. How important do you think tangible items are to clients’ success?

Category Frequency Very Important 9 Important 1 Moderately Important 2 Unimportant 1

Table 43. To the best of your knowledge, how open do you think your court would be to the use of tangible items in your program?

Category Frequency Very Open 1 Somewhat Open 3 Neither For nor Against 6

Table 44. Have you offered or do you currently offer reduction in participants’ program responsibilities as reinforcers/rewards?

Category Frequency Yes 23 No 10 Blank 53

POSITIVE REINFORCEMENT IN DRUG COURTS 110

Table 45. What type(s) of program reductions can participants earn?

Category Frequency Reduced meetings/check ins 7 Reduced court sessions 8 Reduced drug screens/tests 5 Credit for fees 5 Reduced counseling sessions 1 Move up a phase 1 Extended curfew 4 Reduce community service 4 Leave court early 4 Less requirements overall 1 Release from home confinement 1 Reduce sanctions 1 Cannot be determined 5

Table 46. When (at what time(s) during the program) can a client earn a reduction in their program responsibilities?

Category Frequency Any time 4 Holidays 0 In first phase, but after an initial period of 30-60 days 2 Any time after 90 days 0 Any time after 120 days 0 Any time after 180 days 1 Weekly 1 Biweekly 0 Monthly 0 Randomly 0 Graduation 0 After achieving a milestone 0 After Phase 1 5 Every court session 0 Phase promotions 5 Need based 0 Cannot be determined 5 POSITIVE REINFORCEMENT IN DRUG COURTS 111

Table 47. How does a client earn a reduction in their program responsibilities (for what behaviors)?

Category Frequency Compliance 17 Fishbowl 0 Not having infractions 0 Perfect compliance for entire court 0 Continued abstinence 6 Attending appointments 0 Community Service 0 Helping a peer 0 Prosocial behaviors 1 Phase advancements 2 Achieving a milestone 0 Need based 0 Cannot be determined 7

Table 48. Who delivers/informs the client of the reduction in program responsibilities?

Category Frequency Judge 19 Coordinator 5 Case manager 2 Drawing/random 0 Any team member 1 Probation officer 0 Treatment provider 1 Cannot be determined 0

Table 49. How many years has your program been providing reductions in program responsibilities to clients?

Category Frequency Less than 1 year 1 1-5 years 9 6-10 year 2 11-15 years 7 16-20 years 3 POSITIVE REINFORCEMENT IN DRUG COURTS 112

Table 50. How important do you think reduction in program responsibilities is to clients’ success?

Category Frequency Very Important 13 Important 8 Moderately Important 1

Table 51. To the best of your knowledge, how open do you think your court would be to the use of reductions in program responsibilities in your program?

Category Frequency Very Open 1 Somewhat Open 2 Neither For or Against 2 Somewhat Not Open 2 Not at all Open 3

Table 52. Have you offered or do you currently offer money as reinforcers/rewards?

Category Frequency Yes 1 No 31 Blank 52

Table 53. When (at what time(s) during the program) can a client earn a monetary reward?

Category Frequency Any time 1

Table 54. How does a client earn a monetary reward (for what behaviors)?

Category Frequency Prosocial behaviors 1 random/drawing 1 POSITIVE REINFORCEMENT IN DRUG COURTS 113

Table 55. How much can be earned?

Category Frequency $100-200 1

Table 56. Who delivers the monetary reward?

Category Frequency Judge 1

Table 57. How many years has your program been providing monetary rewards to clients?

Category Frequency 6-10 years 1

Table 58. How important do you think that monetary rewards are to clients’ success?

Category Frequency Important 1

Table 59. To the best of your knowledge, how open do you think your court would be to the use of monetary rewards in your program?

Category Frequency Neither For or 4 Against Somewhat Not 5 Open Not at all Open 22

POSITIVE REINFORCEMENT IN DRUG COURTS 114

Table 60. Have you offered or do you currently offer verbal praise as reinforcers/rewards?

Category Frequency Yes 32 No 0 Blank 54

Table 61. When (at what time(s) during the program) can a client earn verbal praise?

Category Frequency Any time 17 Holidays 0 In first phase, but after an initial period of 30-60 days 1 Any time after 90 days 0 Any time after 120 days 0 Any time after 180 days 0 Daily 1 Weekly 2 Biweekly 0 Monthly 0 Randomly 2 Graduation 0 After achieving a milestone 0 After phase 1 0 Court sessions 5 Case management meetings 2 Phase promotions 0 Need based 0 Cannot be determined 5

POSITIVE REINFORCEMENT IN DRUG COURTS 115

Table 62. How does a client earn verbal praise (for what behaviors)?

Category Frequency Compliance 27 Fishbowl 0 Not having infractions 3 Perfect individual compliance 0 Perfect compliance for entire court 0 Continued abstinence 6 Attending appointments 0 Prosocial behaviors 16 Helping a peer 0 Phase advancements 2 Achieving a milestone 5 Need based 0 Cannot be determined 10

Table 63. Who delivers the verbal praise?

Category Frequency Judge 27 Coordinator 5 Case manager 3 Drawing/random 0 Team members 15 Probation officer 2 Treatment provider 1 Law enforcement 1 Legal team members 5 Entire court room 1 Other participants 1 Cannot be determined 1

POSITIVE REINFORCEMENT IN DRUG COURTS 116

Table 64. How many years has your program been providing verbal praise to clients?

Category Frequency Less than 1 year 1 1-5 years 7 6-10 year 7 11-15 years 2 16-20 years 14 Cannot be determined 1

Table 65. How important do you think that verbal praise is to clients’ success?

Category Frequency Very Important 26 Important 6

Table 66. To the best of your knowledge, how open do you think your court would be to the use of verbal praise in your program?

Category Frequency No responses because all participants endorsed using verbal praise 0

Table 67. Have you offered or do you currently offer certificates of accomplishment as reinforcers/rewards?

Category Frequency Yes 25 No 7 Blank 54

POSITIVE REINFORCEMENT IN DRUG COURTS 117

Table 68. When (at what time(s) during the program) can a client earn a certificate of accomplishment?

Category Frequency Any time 2 Holidays 0 At Start 1 In first phase, but after an initial period of 30-60 days 0 Any time after 90 days 1 Any time after 120 days 0 Any time after 180 days 0 Daily 0 Weekly 0 Biweekly 0 Monthly 0 Randomly 0 Graduation 14 After achieving a milestone 6 After phase 1 0 Every court session 1 Case management meetings 0 Phase promotions 15 Need based 0 Cannot be determined 1

POSITIVE REINFORCEMENT IN DRUG COURTS 118

Table 69. How does a client earn a certificate of accomplishment (for what behaviors)?

Category Frequency Compliance 10 Fishbowl 0 Not having infractions 1 Perfect individual compliance 0 Perfect compliance for entire court 0 Continued abstinence 4 Attending appointments 0 Prosocial behaviors 2 Helping a peer 0 Phase advancements 11 Achieving a milestone 1 Graduating program 11 Need based 0

Table 70. Who delivers the certificate of accomplishment?

Category Frequency Judge 22 Coordinator 4 Case manager 0 Drawing/random 0 Any team member 0 Probation officer 0 Treatment provider 2 Law enforcement 0 Legal team 1 Entire court room 0 Cannot be determined 0

POSITIVE REINFORCEMENT IN DRUG COURTS 119

Table 71. How many years has your program been providing certificates of accomplishment to clients?

Category Frequency Less than 1 year 0 1-5 years 7 6-10 year 2 11-15 years 8 16-20 years 7 Cannot be determined 1

Table 72. How important does your court think certificates of accomplishments are to clients’ success?

Category Frequency Very Important 16 Important 8 Moderately Important 1

Table 73. To the best of your knowledge, how open do you think your court would be to the use of certificates of accomplishment in your program?

Category Frequency Very Open 4 Somewhat Open 1 Neither For or Against 2

POSITIVE REINFORCEMENT IN DRUG COURTS 120

Table 74.

“Other” reinforcers

How Category Frequency When How Delivery Long Importance

No 18 Yes 5 Sing Happy 1 Birthday/ Stay sober Court room 20 yrs Very Anniversary important Birthday

Time spent w/ 1 Phase 3 or 4 Meet goals Judge 3 yrs Very important judge/team

Pay for referrals 1 Daily Compliance Coordinator 5 yrs Very important

Earn money back 1 Graduation Drug free, Judge 9 yrs Important job, no charges Standing ovation 1 Weekly “Best of the Judge/ staff 5 yrs Important week”

POSITIVE REINFORCEMENT IN DRUG COURTS 121

Table 75. If applicable, what initiated or caused you to implement reinforcers/rewards into your program?

Category Frequency Research on effectiveness of PR 3 Unknown 7 Best practices 13 To motivate/encourage clients 6 Training 3

Table 76. If applicable, how are the reinforcers/rewards funded?

Category Frequency Unknown 2 Part of budget/program funding 11 Grants 5 Donations 14 Fundraising 1 Participant fees 8 Free 2 Sales tax 2

POSITIVE REINFORCEMENT IN DRUG COURTS 122

Table 77. Summary of perceived importance of reinforcer

Very Important 91 certificates of accomplishments 16 food (as a reinforcer) 7 gift cards/certificates 13 reduction in program responsibilities 13 tangible items 9 tokens/coupons/vouchers 7 verbal praise 26 Important 49 certificates of accomplishments 8 food (as a reinforcer) 2 gift cards/certificates 15 monetary rewards 1 reduction in program responsibilities 8 tangible items 1 tokens/coupons/vouchers 8 verbal praise 6 Moderately Important 8 certificates of accomplishments 1 food (as a reinforcer) 3 gift cards/certificates 1 reduction in program responsibilities 1 tangible items 2 Of Little Importance 4 food (as a reinforcer) 2 gift cards/certificates 2 Unimportant 2 food (as a reinforcer) 1 tangible items 1 Note: Totals may differ due to missing responses to certain items. POSITIVE REINFORCEMENT IN DRUG COURTS 123

Figures

Figure 1. Flow diagram of participant sampling process. This figure illustrates how participants were recruited to participate in the study. N = population sample of drug court coordinators in the United States of America, n = number of drug court coordinators that participated in the study. POSITIVE REINFORCEMENT IN DRUG COURTS 124

Figure 2. Participants’ geographical regions. This figure illustrates drug court coordinators’ geographical locations of their drug courts. It represents a total of 13 states. This study had representation from each region as defined by the US Census Bureau. n = number of drug courts represented in the study from that specific geographical region. U.S. Census Bureau. U.S. census bureau regions: West, Midwest, south, and northeast. Retrieved from: http://www.thomaslegion.net/uscensusbureauregionsthewestthemidwestthesouthandthenortheast. html Key: Number of states in region (number of courts in region)